Provider Demographics
NPI:1417019035
Name:BECKSTROM, LISA CAROL (MA, CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:CAROL
Last Name:BECKSTROM
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Gender:F
Credentials:MA, CCC-SLP
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Mailing Address - Street 1:5641 ADAIR AVE N
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL
Mailing Address - State:MN
Mailing Address - Zip Code:55429-2706
Mailing Address - Country:US
Mailing Address - Phone:952-993-5498
Mailing Address - Fax:952-993-5585
Practice Address - Street 1:6500 EXCELSIOR BLVD
Practice Address - Street 2:REHAB SERVICES - SPEECH PATHOLOGY
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55426-4702
Practice Address - Country:US
Practice Address - Phone:952-993-5498
Practice Address - Fax:952-993-5585
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN5642235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist