Provider Demographics
NPI:1932703782
Name:MIDTHUN, MARINA (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MARINA
Middle Name:
Last Name:MIDTHUN
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2110 SILVER BELL RD
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55122-1024
Mailing Address - Country:US
Mailing Address - Phone:651-452-3499
Mailing Address - Fax:952-767-4211
Practice Address - Street 1:1705 ROSEWOOD AVE S
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-3641
Practice Address - Country:US
Practice Address - Phone:715-699-3893
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-23
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist