Provider Demographics
NPI:1659912400
Name:BERRETH, KONI (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KONI
Middle Name:
Last Name:BERRETH
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3810 JACKSON BLVD
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702-3246
Mailing Address - Country:US
Mailing Address - Phone:605-484-2303
Mailing Address - Fax:
Practice Address - Street 1:3810 JACKSON BLVD
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57702-3246
Practice Address - Country:US
Practice Address - Phone:605-484-2303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-03
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD211-SLP235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist