Provider Demographics
NPI:1871289959
Name:LESOURD, MARY R
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:R
Last Name:LESOURD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12455 RIDGEDALE DR STE 203
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55305-1786
Mailing Address - Country:US
Mailing Address - Phone:952-314-7035
Mailing Address - Fax:
Practice Address - Street 1:12455 RIDGEDALE DR STE 203
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55305-1786
Practice Address - Country:US
Practice Address - Phone:952-314-7035
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-12
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist