Provider Demographics
NPI:1912242223
Name:WILLISTON CENTER FOR PEDIATRIC THERAPY
Entity Type:Organization
Organization Name:WILLISTON CENTER FOR PEDIATRIC THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRITTANY
Authorized Official - Middle Name:K
Authorized Official - Last Name:VICKERS
Authorized Official - Suffix:
Authorized Official - Credentials:CCC-SLP
Authorized Official - Phone:701-572-5974
Mailing Address - Street 1:205 11TH ST E
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:ND
Mailing Address - Zip Code:58801-5445
Mailing Address - Country:US
Mailing Address - Phone:701-572-5974
Mailing Address - Fax:866-279-5137
Practice Address - Street 1:1106 2ND ST W
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:ND
Practice Address - Zip Code:58801-5804
Practice Address - Country:US
Practice Address - Phone:701-572-5974
Practice Address - Fax:866-279-5137
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-28
Last Update Date:2013-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1036235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND56183Medicaid