Provider Demographics
NPI:1225387202
Name:EITTREIM, MICHAEL (MA)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:EITTREIM
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:445 GALTIER ST
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55103-2358
Mailing Address - Country:US
Mailing Address - Phone:651-251-3357
Mailing Address - Fax:651-251-3430
Practice Address - Street 1:445 GALTIER ST
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55103-2358
Practice Address - Country:US
Practice Address - Phone:651-251-3357
Practice Address - Fax:651-251-3430
Is Sole Proprietor?:No
Enumeration Date:2012-09-05
Last Update Date:2012-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8997235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist