Basic Information
Provider Information | |||||||||
NPI: | 1033689674 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ROFFERS | ||||||||
FirstName: | NICHOLAS | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1512 VALLEY DR | ||||||||
Address2: |   | ||||||||
City: | BURNSVILLE | ||||||||
State: | MN | ||||||||
PostalCode: | 553372334 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9522208205 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3400 W 66TH ST | ||||||||
Address2: |   | ||||||||
City: | EDINA | ||||||||
State: | MN | ||||||||
PostalCode: | 554352111 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9529141965 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/27/2018 | ||||||||
LastUpdateDate: | 03/14/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X |   |   | N |   | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   | 235Z00000X | 9878 | MN | Y |   | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   |
No ID Information.