Provider Demographics
NPI:1255487435
Name:ROUTH, KENDRA M
Entity Type:Individual
Prefix:MRS
First Name:KENDRA
Middle Name:M
Last Name:ROUTH
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 1:207 34TH AVE E
Mailing Address - Street 2:
Mailing Address - City:WEST FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58078-7975
Mailing Address - Country:US
Mailing Address - Phone:218-329-5888
Mailing Address - Fax:218-329-5888
Practice Address - Street 1:207 34TH AVE E
Practice Address - Street 2:
Practice Address - City:WEST FARGO
Practice Address - State:ND
Practice Address - Zip Code:58078-7975
Practice Address - Country:US
Practice Address - Phone:218-329-5888
Practice Address - Fax:218-329-5888
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-28
Last Update Date:2015-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND942235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND51084Medicaid
ND26713Medicare UPIN