Healthcare Provider Details

I. General information

NPI: 1972428225
Provider Name (Legal Business Name): WILD ROOTS SPEECH & LANGUAGE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2026
Last Update Date: 08/13/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

604 1ST AVE E
EUREKA MT
59917
US

IV. Provider business mailing address

PO BOX 123
EUREKA MT
59917-0123
US

V. Phone/Fax

Practice location:
  • Phone: 316-644-2077
  • Fax:
Mailing address:
  • Phone: 316-644-2077
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0700X
TaxonomyHearing and Speech Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: AMANDA G ERICKSON
Title or Position: SPEECH PATHOLOGIST
Credential: CCC-SLP
Phone: 316-644-2077