Provider Demographics
NPI:1689850406
Name:CHEOLIS, LIBBY BROCK (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:LIBBY
Middle Name:BROCK
Last Name:CHEOLIS
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:ELISABETH
Other - Middle Name:MERRITT
Other - Last Name:GROVES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, CCC-SLP
Mailing Address - Street 1:6573 KIMBERLY LN N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55311-3961
Mailing Address - Country:US
Mailing Address - Phone:612-210-2412
Mailing Address - Fax:
Practice Address - Street 1:6900 78TH AVE N STE 101
Practice Address - Street 2:
Practice Address - City:BROOKLYN PARK
Practice Address - State:MN
Practice Address - Zip Code:55445-2719
Practice Address - Country:US
Practice Address - Phone:763-432-6875
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-10
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7792235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist