Basic Information
| Provider Information | |||||||||
| NPI: | 1790018638 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEAN | ||||||||
| FirstName: | MARGARET | ||||||||
| MiddleName: | SUE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D./CCC-A | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GILLIHAN | ||||||||
| OtherFirstName: | MARGARET | ||||||||
| OtherMiddleName: | SUE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6700 WASHINGTON AVE S | ||||||||
| Address2: | |||||||||
| City: | EDEN PRAIRIE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553443405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6123511529 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1001 BUCHANAN DR STE 11 | ||||||||
| Address2: | |||||||||
| City: | BURNET | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786112329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9565442783 | ||||||||
| FaxNumber: | 9565445160 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/10/2009 | ||||||||
| LastUpdateDate: | 01/27/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | 51320 | TX | N | Speech, Language and Hearing Service Providers | Audiologist | 237700000X | TX | N | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist | 237600000X | 51320 | TX | Y | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter |
ID Information
| ID | Type | State | Issuer | Description | 2072050-03 | 01 | TX | MEDICARE | OTHER |