Provider Demographics
NPI:1306384649
Name:MINNESOTA STATE UNIVERSITY-MOORHEAD
Entity Type:Organization
Organization Name:MINNESOTA STATE UNIVERSITY-MOORHEAD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH LANGUAGE PATHOLOGIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:MARIAN
Authorized Official - Last Name:IVERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MS; CCC-SLP
Authorized Official - Phone:218-477-2385
Mailing Address - Street 1:1104 7TH AVE S
Mailing Address - Street 2:
Mailing Address - City:MOORHEAD
Mailing Address - State:MN
Mailing Address - Zip Code:56563-0001
Mailing Address - Country:US
Mailing Address - Phone:218-477-2385
Mailing Address - Fax:
Practice Address - Street 1:1104 7TH AVE S
Practice Address - Street 2:
Practice Address - City:MOORHEAD
Practice Address - State:MN
Practice Address - Zip Code:56563-0001
Practice Address - Country:US
Practice Address - Phone:218-477-2385
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MINNESOTA STATE COLLEGES AND UNIVERSITIES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-02-07
Last Update Date:2017-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5512261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN5512OtherMDE LICENSE