1780773556 NPI number — DR. LORETTA MAE KNUTSON PH.D., PT, PCS

Table of content: DR. LORETTA MAE KNUTSON PH.D., PT, PCS (NPI 1780773556)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780773556 NPI number — DR. LORETTA MAE KNUTSON PH.D., PT, PCS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KNUTSON
Provider First Name:
LORETTA
Provider Middle Name:
MAE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D., PT, PCS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LOUGH
Provider Other First Name:
LORETTA
Provider Other Middle Name:
KNUTSON
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PH.D., PT, PCS
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1780773556
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
901 S NATIONAL AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65897-0027
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-836-3070
Provider Business Mailing Address Fax Number:
417-836-3032

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
606 E CHERRY ST
Provider Second Line Business Practice Location Address:
ROOM 100
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65806-3401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-836-3070
Provider Business Practice Location Address Fax Number:
417-836-3032
Provider Enumeration Date:
10/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  2002002058 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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