Basic Information
| Provider Information | |||||||||
| NPI: | 1811271745 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STOTERAU | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | DAWN | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MS CCC SLP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DIFFELY | ||||||||
| OtherFirstName: | LISA | ||||||||
| OtherMiddleName: | DAWN | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1602 5 1/2 AVE NE | ||||||||
| Address2: | |||||||||
| City: | JAMESTOWN | ||||||||
| State: | ND | ||||||||
| PostalCode: | 584012530 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7016590888 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 501 19TH ST NE | ||||||||
| Address2: | |||||||||
| City: | JAMESTOWN | ||||||||
| State: | ND | ||||||||
| PostalCode: | 584012541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012525660 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2011 | ||||||||
| LastUpdateDate: | 10/11/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 997 | ND | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.