Provider Demographics
NPI:1609967223
Name:TICKLE, ELIZABETH C (MA CCC/SLP)
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:C
Last Name:TICKLE
Suffix:
Gender:F
Credentials:MA CCC/SLP
Other - Prefix:MISS
Other - First Name:ELIZABETH
Other - Middle Name:G
Other - Last Name:CRUSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA CCC/SLP
Mailing Address - Street 1:1322 ALTON ST #212
Mailing Address - Street 2:
Mailing Address - City:ST PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55116
Mailing Address - Country:US
Mailing Address - Phone:651-247-5966
Mailing Address - Fax:
Practice Address - Street 1:900 WEST 94TH ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55420
Practice Address - Country:US
Practice Address - Phone:952-885-0418
Practice Address - Fax:952-885-0173
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2010-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8021235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist