MEDICARE: CAROL HASSEBROEK SPEECH PATHOLOGY SERVICES, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	8910	MN

General Provider Information

NPI Number	:	1407238470
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CAROL HASSEBROEK SPEECH PATHOLOGY SERVICES, LLC

Provider Business Mailing Address
First Line	:	5650 W 36TH ST APT 206
Second Line	:	#206
City	:	ST LOUIS PARK
State	:	MN
Zip	:	55416-2543
Country	:	US
Telephone Number	:	612-610-1040
Fax Number	:

Provider Business Practice Location Address
First Line	:	5650 W 36TH ST APT 206
Second Line	:	#206
City	:	ST LOUIS PARK
State	:	MN
Zip	:	55416-2543
Country	:	US
Telephone Number	:	612-618-1040
Fax Number	:

Authorized Official
Title or Position	:	OWNER/SPEECH-LANGUAGE PATHOLOGIST
Name	:	MS. CAROL ANN HASSEBROEK
Credential	:	M.A., CCC-SLP
Telephone Number	:	612-618-1040

Provider Enumeration Date	:	06/25/2015
Last Update Date	:	10/02/2016

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