Provider Demographics
NPI:1588217301
Name:ON SPOT THERAPY AND OROFACIAL MYOLOGY, LLC
Entity Type:Organization
Organization Name:ON SPOT THERAPY AND OROFACIAL MYOLOGY, LLC
Other - Org Name:ON SPOT THERAPY AND OROFACIAL MYOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TESSA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:RASMUSSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MS CCC-SLP
Authorized Official - Phone:701-532-1507
Mailing Address - Street 1:4103 40TH AVE S
Mailing Address - Street 2:
Mailing Address - City:MOORHEAD
Mailing Address - State:MN
Mailing Address - Zip Code:56560-7503
Mailing Address - Country:US
Mailing Address - Phone:701-212-5926
Mailing Address - Fax:
Practice Address - Street 1:4500 36TH AVE S STE 200
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-5275
Practice Address - Country:US
Practice Address - Phone:701-532-1507
Practice Address - Fax:701-532-1529
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-21
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty
No261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and SpeechGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND77101Medicaid