Provider Demographics
NPI:1518139120
Name:SPEECH PLACE LLC
Entity Type:Organization
Organization Name:SPEECH PLACE LLC
Other - Org Name:SPEECH PLACE
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:J
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:SLP
Authorized Official - Phone:218-333-1571
Mailing Address - Street 1:29 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WACONIA
Mailing Address - State:MN
Mailing Address - Zip Code:55387-1114
Mailing Address - Country:US
Mailing Address - Phone:952-442-7015
Mailing Address - Fax:952-442-7016
Practice Address - Street 1:677 ANNE ST NW
Practice Address - Street 2:SUITE E
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-4390
Practice Address - Country:US
Practice Address - Phone:218-333-1571
Practice Address - Fax:218-333-0948
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-24
Last Update Date:2011-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7693235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN589185100Medicaid