Healthcare Provider Details

I. General information

NPI: 1487545307
Provider Name (Legal Business Name): SUNSHINE PEDIATRIC THERAPY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2025
Last Update Date: 07/10/2025
Certification Date: 07/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 1ST AVE SE
MINOT ND
58701-3991
US

IV. Provider business mailing address

1208 13TH ST SW
MINOT ND
58701-5784
US

V. Phone/Fax

Practice location:
  • Phone: 701-500-0104
  • Fax:
Mailing address:
  • Phone: 701-500-0104
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: CANDACE RAE LARSON
Title or Position: OWNER/SPEECH-LANGUAGE PATHOLOGIST
Credential: M.S.
Phone: 701-500-0104