Healthcare Provider Details

I. General information

NPI: 1134983794
Provider Name (Legal Business Name): SAND CANYON THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2024
Last Update Date: 03/04/2024
Certification Date: 03/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 BOX BUTTE AVE
HEMINGFORD NE
69348-9706
US

IV. Provider business mailing address

PO BOX 794
HEMINGFORD NE
69348-0794
US

V. Phone/Fax

Practice location:
  • Phone: 308-760-8431
  • Fax:
Mailing address:
  • Phone: 308-760-8431
  • 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: JENILEE K WOLTMAN
Title or Position: SPEECH LANGUAGE PATHOLOGIST, OWNER
Credential: CCC-SLP
Phone: 308-760-8431