Provider Demographics
NPI:1073771853
Name:MITTAG, LORI L
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:L
Last Name:MITTAG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 3RD ST E
Mailing Address - Street 2:
Mailing Address - City:WEST FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58078-1817
Mailing Address - Country:US
Mailing Address - Phone:701-356-2115
Mailing Address - Fax:701-356-2116
Practice Address - Street 1:109 3RD ST E
Practice Address - Street 2:
Practice Address - City:WEST FARGO
Practice Address - State:ND
Practice Address - Zip Code:58078-1817
Practice Address - Country:US
Practice Address - Phone:701-356-2115
Practice Address - Fax:701-356-2116
Is Sole Proprietor?:No
Enumeration Date:2008-05-28
Last Update Date:2008-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1025235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND59798Medicaid