Healthcare Provider Details

I. General information

NPI: 1386142339
Provider Name (Legal Business Name): GARRY LEE WOESSNER MA-CCC SLP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/24/2018
Last Update Date: 01/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6602 SCANDIA RD
EDINA MN
55439-1153
US

IV. Provider business mailing address

6602 SCANDIA RD
EDINA MN
55439-1153
US

V. Phone/Fax

Practice location:
  • Phone: 612-670-1956
  • Fax:
Mailing address:
  • Phone: 612-670-1956
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number7467
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: