Provider Demographics
NPI:1861497000
Name:BOFENKAMP, STEWART P (CCC-A)
Entity Type:Individual
Prefix:
First Name:STEWART
Middle Name:P
Last Name:BOFENKAMP
Suffix:
Gender:M
Credentials:CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:605-328-9556
Mailing Address - Fax:605-328-9501
Practice Address - Street 1:1310 W 22ND ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-1501
Practice Address - Country:US
Practice Address - Phone:605-328-8200
Practice Address - Fax:605-328-8201
Is Sole Proprietor?:No
Enumeration Date:2005-06-15
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD5231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5832902Medicaid
SD640004499Medicare PIN
SDD25585Medicare UPIN
SDS40456Medicare PIN