Healthcare Provider Details

I. General information

NPI: 1053450742
Provider Name (Legal Business Name): CHILDREN'S THERAPY CTR, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3455 153RD ST W
ROSEMOUNT MN
55068-4946
US

IV. Provider business mailing address

4058 DEERWOOD TRL
EAGAN MN
55122-1889
US

V. Phone/Fax

Practice location:
  • Phone: 651-423-0644
  • Fax:
Mailing address:
  • Phone: 651-994-9644
  • Fax: 651-994-8962

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: SUSAN ANN FULLER
Title or Position: OWNER
Credential: OTRL
Phone: 651-994-9644