Provider Demographics
NPI:1861792376
Name:WHILEY, SIMONA RAE (CMT)
Entity type:Individual
Prefix:
First Name:SIMONA
Middle Name:RAE
Last Name:WHILEY
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3251 LOUISIANA AVE S
Mailing Address - Street 2:UNIT 307
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55426-4263
Mailing Address - Country:US
Mailing Address - Phone:612-387-6044
Mailing Address - Fax:
Practice Address - Street 1:109 BUSHAWAY RD
Practice Address - Street 2:SUITE 200
Practice Address - City:WAYZATA
Practice Address - State:MN
Practice Address - Zip Code:55391-1945
Practice Address - Country:US
Practice Address - Phone:612-387-6044
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-31
Last Update Date:2010-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2010-81225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist