Provider Demographics
NPI:1457798910
Name:DETTLING, ELIZABETH E (SLP)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:E
Last Name:DETTLING
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4948 RUSSELL AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55410-1915
Mailing Address - Country:US
Mailing Address - Phone:612-807-6423
Mailing Address - Fax:
Practice Address - Street 1:4948 RUSSELL AVE S
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55410-1915
Practice Address - Country:US
Practice Address - Phone:612-807-6423
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-23
Last Update Date:2013-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6478235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist