Provider Demographics
NPI:1649394933
Name:SOUTH METRO SPEECH SERVICES, LLC
Entity Type:Organization
Organization Name:SOUTH METRO SPEECH SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH & LANGUAGE PATHOLOGIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:TRISHA
Authorized Official - Middle Name:ROXANNE
Authorized Official - Last Name:WITMER
Authorized Official - Suffix:
Authorized Official - Credentials:MA, CCC-SLP
Authorized Official - Phone:612-807-3723
Mailing Address - Street 1:6490 OXFORD PL
Mailing Address - Street 2:
Mailing Address - City:SHAKOPEE
Mailing Address - State:MN
Mailing Address - Zip Code:55379-7063
Mailing Address - Country:US
Mailing Address - Phone:612-807-3723
Mailing Address - Fax:
Practice Address - Street 1:327 MARSCHALL RD STE 390
Practice Address - Street 2:
Practice Address - City:SHAKOPEE
Practice Address - State:MN
Practice Address - Zip Code:55379-1700
Practice Address - Country:US
Practice Address - Phone:612-807-3723
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5928261QH0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and Speech
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN513L2SOOtherBLUE CROSS BLUE SHIELD