Provider Demographics
NPI:1376819771
Name:TATE, ANNIE (MA, CCC SLP)
Entity Type:Individual
Prefix:
First Name:ANNIE
Middle Name:
Last Name:TATE
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 1:561 WEST 7TH STREET
Mailing Address - Street 2:
Mailing Address - City:ST. PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55102
Mailing Address - Country:US
Mailing Address - Phone:651-225-4558
Mailing Address - Fax:651-225-9474
Practice Address - Street 1:1260 WEST COUNTY ROAD E
Practice Address - Street 2:
Practice Address - City:ARDEN HILLS
Practice Address - State:MN
Practice Address - Zip Code:55112
Practice Address - Country:US
Practice Address - Phone:651-639-0942
Practice Address - Fax:651-639-1718
Is Sole Proprietor?:No
Enumeration Date:2012-03-29
Last Update Date:2012-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8501235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist