Healthcare Provider Details

I. General information

NPI: 1346366044
Provider Name (Legal Business Name): STATE OF SOUTH DAKOTA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2007
Last Update Date: 09/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

414 E CLARK ST
VERMILLION SD
57069-2307
US

IV. Provider business mailing address

414 E CLARK ST
VERMILLION SD
57069-2307
US

V. Phone/Fax

Practice location:
  • Phone: 605-677-5474
  • Fax: 605-677-5767
Mailing address:
  • Phone: 605-677-5474
  • Fax: 605-677-5767

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number37
License Number StateSD
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: DR. TERI JAMES BELLIS
Title or Position: DEPARTMENT CHAIR
Credential: PHD,CCC-A,FAAA
Phone: 605-677-5474