Provider Demographics
NPI:1841609989
Name:EGGEBRAATEN, NOAH RENSEN (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:NOAH
Middle Name:RENSEN
Last Name:EGGEBRAATEN
Suffix:
Gender:M
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 W FOUNTAIN ST
Mailing Address - Street 2:
Mailing Address - City:ALBERT LEA
Mailing Address - State:MN
Mailing Address - Zip Code:56007-2437
Mailing Address - Country:US
Mailing Address - Phone:507-668-2900
Mailing Address - Fax:
Practice Address - Street 1:404 W FOUNTAIN ST
Practice Address - Street 2:
Practice Address - City:ALBERT LEA
Practice Address - State:MN
Practice Address - Zip Code:56007-2437
Practice Address - Country:US
Practice Address - Phone:507-668-2900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-02
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMC-5562235Z00000X
MN9771235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist