Healthcare Provider Details

I. General information

NPI: 1760196638
Provider Name (Legal Business Name): LYDIA MARIE TEEGERSTROM AUD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2023
Last Update Date: 05/28/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 COMANCHE RD
FORT MEADE SD
57741-1002
US

IV. Provider business mailing address

113 COMANCHE RD
FORT MEADE SD
57741-1002
US

V. Phone/Fax

Practice location:
  • Phone: 605-347-2511
  • Fax:
Mailing address:
  • Phone: 605-347-2511
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: