Healthcare Provider Details

I. General information

NPI: 1548674195
Provider Name (Legal Business Name): ALISSA BERTHIAUME
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2014
Last Update Date: 06/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1935 COUNTY ROAD B2 W 100
ROSEVILLE MN
55113-2729
US

IV. Provider business mailing address

1935 COUNTY ROAD B2 W 100
ROSEVILLE MN
55113-2729
US

V. Phone/Fax

Practice location:
  • Phone: 651-636-4155
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number9299
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: