Provider Demographics
NPI:1730434267
Name:DESMARAIS, KIRSTEN LEE (PT)
Entity type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:LEE
Last Name:DESMARAIS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7825 3RD ST N STE 105
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55128-5444
Mailing Address - Country:US
Mailing Address - Phone:952-835-4512
Mailing Address - Fax:952-516-5655
Practice Address - Street 1:1029 W CENTRAL ENTRANCE
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55811
Practice Address - Country:US
Practice Address - Phone:952-835-4512
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-20
Last Update Date:2018-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9075225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist