Provider Demographics
NPI:1235597097
Name:TEGELS, MARTHA (MA, CCC/SLP)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:
Last Name:TEGELS
Suffix:
Gender:F
Credentials:MA, CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1647 SEASHELL LANE
Mailing Address - Street 2:
Mailing Address - City:WACONIA
Mailing Address - State:MN
Mailing Address - Zip Code:55387-5041
Mailing Address - Country:US
Mailing Address - Phone:218-851-3050
Mailing Address - Fax:
Practice Address - Street 1:1647 SEASHELL LN
Practice Address - Street 2:
Practice Address - City:WACONIA
Practice Address - State:MN
Practice Address - Zip Code:55387-1054
Practice Address - Country:US
Practice Address - Phone:218-851-3050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-08
Last Update Date:2016-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5914235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN5914OtherMN DEPT OF HEALTH
01041419OtherAMERICAN SPEECH AND HEARING ASSOCIATION