Provider Demographics
NPI:1235649419
Name:MOEN, ALLYSON LEIGH (PT, DPT, ATC)
Entity type:Individual
Prefix:
First Name:ALLYSON
Middle Name:LEIGH
Last Name:MOEN
Suffix:
Gender:F
Credentials:PT, DPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3036 W LAKE ST UNIT 333
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55416-5242
Mailing Address - Country:US
Mailing Address - Phone:563-543-3875
Mailing Address - Fax:
Practice Address - Street 1:6515 BARRIE RD STE 100
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-2364
Practice Address - Country:US
Practice Address - Phone:952-922-5019
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-02
Last Update Date:2017-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10917225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist