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General NPI Number Information
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NPI Number | 1164055513
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Entity Type | Organization
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Legal Business Name | EXPRESSION PEDIATRIC THERAPY, PLLC
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Dates
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Enumeration Date | 02/13/2020
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Last Update Date | 01/21/2024
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Provider Practice Location Address
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Address Line | 1340 W VILLARD ST STE A
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City | DICKINSON
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State | ND
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Zip | 58601-4632
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Country | US
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Telephone | 701-590-9116
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Fax |
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Provider Business Mailing Address
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Address Line | 2212 3RD ST W
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City | DICKINSON
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State | ND
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Zip | 58601-2414
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Country | US
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Telephone | 509-981-3998
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Fax |
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Authorized Official
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Title or Position | SPEECH-LANGUAGE PATHOLOGIST
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Name | MACKENZIE M WOODWORTH
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Credential | MS
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Telephone | 509-981-3998
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number |
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License Number State |
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