Basic Information
| Provider Information | |||||||||
| NPI: | 1497982664 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROBERTS | ||||||||
| FirstName: | MINDY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | SLP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | UDEN | ||||||||
| OtherFirstName: | MINDAY | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | SLP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 5285 | ||||||||
| Address2: | |||||||||
| City: | GRAND ISLAND | ||||||||
| State: | NE | ||||||||
| PostalCode: | 688025285 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3083820344 | ||||||||
| FaxNumber: | 3083823241 | ||||||||
| Practice Location | |||||||||
| Address1: | 3601 CIMARRON PLZ | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | HASTINGS | ||||||||
| State: | NE | ||||||||
| PostalCode: | 689012884 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4024632077 | ||||||||
| FaxNumber: | 4024632062 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2009 | ||||||||
| LastUpdateDate: | 01/22/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 1323 | NE | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.