Healthcare Provider Details

I. General information

NPI: 1023422946
Provider Name (Legal Business Name): INDEPENDENCE SPEECH THERAPY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2014
Last Update Date: 06/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7274 108TH AVE SE
LAMOURE ND
58458-9409
US

IV. Provider business mailing address

7274 108TH AVE SE
LAMOURE ND
58458-9409
US

V. Phone/Fax

Practice location:
  • Phone: 701-883-5464
  • Fax: 701-883-5464
Mailing address:
  • Phone: 701-883-5464
  • Fax: 701-883-5464

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number1271
License Number StateND

VIII. Authorized Official

Name: MR. TOBY LEE THIELGES
Title or Position: PRESIDENT
Credential: PT
Phone: 701-883-5464