Healthcare Provider Details

I. General information

NPI: 1689850406
Provider Name (Legal Business Name): LIBBY BROCK CHEOLIS MA, CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELISABETH MERRITT GROVES MA, CCC-SLP

II. Dates (important events)

Enumeration Date: 01/10/2008
Last Update Date: 08/10/2021
Certification Date: 08/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6900 78TH AVE N STE 101
BROOKLYN PARK MN
55445-2719
US

IV. Provider business mailing address

6573 KIMBERLY LN N
MAPLE GROVE MN
55311-3961
US

V. Phone/Fax

Practice location:
  • Phone: 763-432-6875
  • Fax:
Mailing address:
  • Phone: 612-210-2412
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number7792
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: