Provider Demographics
NPI:1083150338
Name:EKBERG, AMY
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:EKBERG
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 1:521 ARLINGTON AVE W
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55117-3502
Mailing Address - Country:US
Mailing Address - Phone:651-402-8196
Mailing Address - Fax:
Practice Address - Street 1:1000 LOVELL AVE W
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-4459
Practice Address - Country:US
Practice Address - Phone:651-484-3378
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-10
Last Update Date:2017-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9778235Z00000X
ID3001235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist