1083745244 NPI number — MRS. AMY BETH PEDERSON M.A., CCC-SLP

Table of content: MRS. ELIZABETH MARILYNN BRASHER PTA (NPI 1073647137)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083745244 NPI number — MRS. AMY BETH PEDERSON M.A., CCC-SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PEDERSON
Provider First Name:
AMY
Provider Middle Name:
BETH
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
M.A., 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:
1083745244
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/01/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 266
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCKFORD
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55373-0266
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-961-8310
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7006 GREENWOOD CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROCKFORD
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55373-4581
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-961-8310
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/08/2007

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:  7434 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 235Z00000X , with the licence number: FILE FOLDER # 389213 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 4601172 . This is a "MEDICA PROVIDER NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 146T2PE . This is a "BCBS PARTICIPAT. PROVID.#" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 5727164 . This is a "MINNESOTA TAX ID #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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