Provider Demographics
NPI:1619323136
Name:KORTH, THERESA (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:KORTH
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:
Other - Last Name:BIOLSI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3514 33RD AVE W
Mailing Address - Street 2:UNIT 26
Mailing Address - City:WILLISTON
Mailing Address - State:ND
Mailing Address - Zip Code:58801-6940
Mailing Address - Country:US
Mailing Address - Phone:917-608-7368
Mailing Address - Fax:
Practice Address - Street 1:3514 33RD AVE W
Practice Address - Street 2:UNIT 26
Practice Address - City:WILLISTON
Practice Address - State:ND
Practice Address - Zip Code:58801-6940
Practice Address - Country:US
Practice Address - Phone:917-608-7368
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-13
Last Update Date:2016-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1484235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist