Healthcare Provider Details

I. General information

NPI: 1003723263
Provider Name (Legal Business Name): DEBORAH M MYHRE
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2026
Last Update Date: 08/25/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 MINNESOTA AVE
BIG LAKE MN
55309-8802
US

IV. Provider business mailing address

4420 TYLER ST NE
MINNEAPOLIS MN
55421-3245
US

V. Phone/Fax

Practice location:
  • Phone: 763-262-2567
  • Fax:
Mailing address:
  • Phone: 763-234-1090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number351442
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: