Provider Demographics
NPI:1982203303
Name:WOLLERSHEIM, MADELINE (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MADELINE
Middle Name:
Last Name:WOLLERSHEIM
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:MADELINE
Other - Middle Name:
Other - Last Name:MURPHY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:614 PORTLAND AVE APT 302
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55102-2271
Mailing Address - Country:US
Mailing Address - Phone:952-797-6954
Mailing Address - Fax:
Practice Address - Street 1:1 VETERANS DR
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55417-2309
Practice Address - Country:US
Practice Address - Phone:612-629-7463
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-19
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10312235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist