Healthcare Provider Details

I. General information

NPI: 1447478482
Provider Name (Legal Business Name): ANNETTE RUTH SHOBERG MA CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10671 106TH AVE N
HANOVER MN
55341-4400
US

IV. Provider business mailing address

10671 106TH AVE N
HANOVER MN
55341-4400
US

V. Phone/Fax

Practice location:
  • Phone: 763-498-6550
  • Fax:
Mailing address:
  • Phone: 763-498-6550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number5194
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: