Provider Demographics
NPI:1720417678
Name:FISKUM, GRETA (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:GRETA
Middle Name:
Last Name:FISKUM
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:GRETA
Other - Middle Name:
Other - Last Name:ROCKWOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, CCC-SLP
Mailing Address - Street 1:7991 MEADOWOOD DR
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:MN
Mailing Address - Zip Code:55373-2104
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 PARK ST E
Practice Address - Street 2:
Practice Address - City:ANNANDALE
Practice Address - State:MN
Practice Address - Zip Code:55302-3060
Practice Address - Country:US
Practice Address - Phone:320-274-3432
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-01
Last Update Date:2013-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5917235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist