Provider Demographics
NPI:1447284435
Name:INNOVATIVE THERAPY LLC
Entity type:Organization
Organization Name:INNOVATIVE THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OCCUPATIONAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:JO
Authorized Official - Last Name:DANIELSON
Authorized Official - Suffix:
Authorized Official - Credentials:MAOTR/L
Authorized Official - Phone:612-597-2975
Mailing Address - Street 1:1696 7TH ST NW
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:MN
Mailing Address - Zip Code:55313-5050
Mailing Address - Country:US
Mailing Address - Phone:612-597-2975
Mailing Address - Fax:763-682-1668
Practice Address - Street 1:5480 NATHAN LN N STE 140
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55442-1995
Practice Address - Country:US
Practice Address - Phone:612-597-2975
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2017-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN183942OtherU-CARE
MN128152600Medicaid
MN24-6600Medicare ID - Type Unspecified