Provider Demographics
NPI:1922542919
Name:HEARTLAND HEARING PROFESSIONALS PLLC
Entity Type:Organization
Organization Name:HEARTLAND HEARING PROFESSIONALS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUDIOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:ROSE
Authorized Official - Middle Name:
Authorized Official - Last Name:BRAKKE
Authorized Official - Suffix:
Authorized Official - Credentials:AUD
Authorized Official - Phone:701-430-1017
Mailing Address - Street 1:3139 BLUE STEM DR STE 108
Mailing Address - Street 2:
Mailing Address - City:WEST FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58078-8060
Mailing Address - Country:US
Mailing Address - Phone:701-639-4595
Mailing Address - Fax:
Practice Address - Street 1:3139 BLUE STEM DR STE 108
Practice Address - Street 2:
Practice Address - City:WEST FARGO
Practice Address - State:ND
Practice Address - Zip Code:58078-8060
Practice Address - Country:US
Practice Address - Phone:701-639-4595
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-08
Last Update Date:2016-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND989231HA2400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231HA2400XSpeech, Language and Hearing Service ProvidersAudiologistAssistive Technology PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1023297348Medicaid
ND1458557Medicaid