1013123942 NPI number — SHAUN M HIEMSTRA M.S., CCC-SLP

Table of content: SHAUN M HIEMSTRA M.S., CCC-SLP (NPI 1013123942)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013123942 NPI number — SHAUN M HIEMSTRA M.S., CCC-SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HIEMSTRA
Provider First Name:
SHAUN
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.S., CCC-SLP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013123942
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/24/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
321 GRAND AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RAVENNA
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68869-1321
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
308-452-7154
Provider Business Mailing Address Fax Number:
308-452-3394

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
321 GRAND AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RAVENNA
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68869-1321
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
308-452-7154
Provider Business Practice Location Address Fax Number:
308-452-3394
Provider Enumeration Date:
05/15/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  887 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 06587 . This is a "BCBS" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".




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