Provider Demographics
NPI:1245111947
Name:PHOULAVAN, HAILEY (DPT)
Entity type:Individual
Prefix:
First Name:HAILEY
Middle Name:
Last Name:PHOULAVAN
Suffix:
Gender:X
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:897 REDWELL LN
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55124-8943
Mailing Address - Country:US
Mailing Address - Phone:612-709-1395
Mailing Address - Fax:
Practice Address - Street 1:60 MARIE AVE E STE 203
Practice Address - Street 2:
Practice Address - City:WEST ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55118-5932
Practice Address - Country:US
Practice Address - Phone:651-451-6156
Practice Address - Fax:651-451-0387
Is Sole Proprietor?:No
Enumeration Date:2025-09-09
Last Update Date:2025-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN14100225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist