Basic Information
| Provider Information | |||||||||
| NPI: | 1518139120 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SPEECH PLACE LLC | ||||||||
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| OtherOrganizationName: | SPEECH PLACE | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 29 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | WACONIA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553871114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9524427015 | ||||||||
| FaxNumber: | 9524427016 | ||||||||
| Practice Location | |||||||||
| Address1: | 677 ANNE ST NW | ||||||||
| Address2: | SUITE E | ||||||||
| City: | BEMIDJI | ||||||||
| State: | MN | ||||||||
| PostalCode: | 566014390 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2183331571 | ||||||||
| FaxNumber: | 2183330948 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2008 | ||||||||
| LastUpdateDate: | 05/24/2011 | ||||||||
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| AuthorizedOfficialLastName: | PETERSON | ||||||||
| AuthorizedOfficialFirstName: | NANCY | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2183331571 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | SLP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 7693 | MN | Y | 193400000X SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 589185100 | 05 | MN | MEDICAID |