Basic Information
| Provider Information | |||||||||
| NPI: | 1578677183 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KASARI-DESULME | ||||||||
| FirstName: | MONICA | ||||||||
| MiddleName: | CRISTINA | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1702 UNIVERSITY DR S | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581034940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7013644999 | ||||||||
| FaxNumber: | 7013648476 | ||||||||
| Practice Location | |||||||||
| Address1: | 4289 UGSTAD RD | ||||||||
| Address2: | |||||||||
| City: | HERMANTOWN | ||||||||
| State: | MN | ||||||||
| PostalCode: | 558113615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187863100 | ||||||||
| FaxNumber: | 2185760779 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2006 | ||||||||
| LastUpdateDate: | 06/30/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 5556 | MN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 83453A | 01 | MN | BCBS | OTHER | 116637900 | 05 | MN | MEDICAID |