1518116417 NPI number — TERRANCE RICHARD WOBIG SPEECH LANGUAGE PATH

Table of content: TERRANCE RICHARD WOBIG SPEECH LANGUAGE PATH (NPI 1518116417)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518116417 NPI number — TERRANCE RICHARD WOBIG SPEECH LANGUAGE PATH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WOBIG
Provider First Name:
TERRANCE
Provider Middle Name:
RICHARD
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
SPEECH LANGUAGE PATH
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
JONES
Provider Other First Name:
TERRANCE
Provider Other Middle Name:
RICHARD
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PTA
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1518116417
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/16/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
66 SHADY OAK CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WINONA
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55987-6034
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
507-454-0000
Provider Business Mailing Address Fax Number:
507-454-6724

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
66 SHADY OAK CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WINONA
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55987-6034
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
507-454-0000
Provider Business Practice Location Address Fax Number:
507-454-6724
Provider Enumeration Date:
09/16/2008

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:  5191 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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