Provider Demographics
NPI:1487255295
Name:MYOFASCIAL RELEASE BY KATIE
Entity type:Organization
Organization Name:MYOFASCIAL RELEASE BY KATIE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KATIE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:BRADSHAW
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:612-432-5305
Mailing Address - Street 1:2406 14TH ST W
Mailing Address - Street 2:
Mailing Address - City:WEST FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58078-8441
Mailing Address - Country:US
Mailing Address - Phone:612-432-5305
Mailing Address - Fax:
Practice Address - Street 1:3441 45TH ST S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-8970
Practice Address - Country:US
Practice Address - Phone:701-660-5104
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-06
Last Update Date:2020-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No2251E1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistErgonomicsGroup - Multi-Specialty
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatricsGroup - Multi-Specialty
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSportsGroup - Multi-Specialty
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Multi-Specialty