Provider Demographics
NPI:1407968522
Name:MAGELKY, PHYLLIS JEAN (MS CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:PHYLLIS
Middle Name:JEAN
Last Name:MAGELKY
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:MRS
Other - First Name:PHYLLIS
Other - Middle Name:JEAN
Other - Last Name:MAGELKY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS CCC-SLP
Mailing Address - Street 1:3309 FIECHTNER DR S STE D
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-2375
Mailing Address - Country:US
Mailing Address - Phone:701-364-9070
Mailing Address - Fax:701-364-9071
Practice Address - Street 1:1112 NODAK DR S STE 135
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-8744
Practice Address - Country:US
Practice Address - Phone:701-364-9070
Practice Address - Fax:701-364-9071
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2009-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND320235Z00000X
MN5882235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND27397OtherBLUE CROSS BLUE SHIELD
ND11674OtherBLUE CROSS BLUE SHIELD
MN4043140-00Medicaid
MN5G158N-MAOtherBLUE CROSS/BLUE SHIELD
ND58789Medicaid
MN1033438OtherPREFERRED ONE