Provider Demographics
NPI:1366408114
Name:DUFAULT, MARIALENA I (PT)
Entity type:Individual
Prefix:
First Name:MARIALENA
Middle Name:I
Last Name:DUFAULT
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MARIALENA
Other - Middle Name:I
Other - Last Name:MORALES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:3915 GOLDEN VALLEY RD
Mailing Address - Street 2:COURAGE CENTER
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55422-4298
Mailing Address - Country:US
Mailing Address - Phone:763-520-0709
Mailing Address - Fax:763-520-0355
Practice Address - Street 1:3915 GOLDEN VALLEY RD
Practice Address - Street 2:COURAGE CENTER
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55422-4298
Practice Address - Country:US
Practice Address - Phone:763-520-0709
Practice Address - Fax:763-520-0355
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5855225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
6411176OtherMEDICA
HP43585OtherHEALTH PARTNERS
48Q90MOOtherBCBS MINNESOTA