Healthcare Provider Details

I. General information

NPI: 1114624822
Provider Name (Legal Business Name): EMPOWERED BY SPEECH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2023
Last Update Date: 08/10/2023
Certification Date: 08/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7924 VICTORIA DR # B
VICTORIA MN
55386-2800
US

IV. Provider business mailing address

2619 CLOVER FIELD CIR
CHASKA MN
55318-3233
US

V. Phone/Fax

Practice location:
  • Phone: 952-412-5703
  • Fax:
Mailing address:
  • Phone: 952-412-5703
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QH0700X
TaxonomyHearing and Speech Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TARIA CAMERON
Title or Position: SPEECH LANGUAGE PATHOLOGIST
Credential: MA-CCC,SLP
Phone: 952-412-5703