Provider Demographics
NPI:1457792855
Name:STANISLAW, LARA O (PT)
Entity type:Individual
Prefix:MS
First Name:LARA
Middle Name:O
Last Name:STANISLAW
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1957 PORTLAND AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-5853
Mailing Address - Country:US
Mailing Address - Phone:651-402-5055
Mailing Address - Fax:
Practice Address - Street 1:2151 HAMLINE AVE N
Practice Address - Street 2:SUITE #111
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-4236
Practice Address - Country:US
Practice Address - Phone:651-636-5560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-13
Last Update Date:2013-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8906225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist