Healthcare Provider Details

I. General information

NPI: 1861490690
Provider Name (Legal Business Name): JULIA ANNA BLONIGEN M.S., CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/14/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1882 KILIAN BLVD
ST CLOUD MN
56304
US

IV. Provider business mailing address

1882 KILIAN BLVD
ST CLOUD MN
56304
US

V. Phone/Fax

Practice location:
  • Phone: 320-251-4038
  • Fax: 320-251-4038
Mailing address:
  • Phone: 320-251-4038
  • Fax: 320-251-4038

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number5029
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: