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General NPI Number Information
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NPI Number | 1285080242
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Entity Type | Organization
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Legal Business Name | SPEECH AND LANGUAGE STUDIO OF THE BLACK HILLS
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Dates
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Enumeration Date | 05/09/2016
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Last Update Date | 05/09/2016
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Provider Practice Location Address
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Address Line | 2040 W MAIN ST STE 209
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City | RAPID CITY
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State | SD
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Zip | 57702-2446
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Country | US
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Telephone | 605-431-8501
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Fax |
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Provider Business Mailing Address
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Address Line | 2040 W MAIN ST STE 209
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City | RAPID CITY
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State | SD
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Zip | 57702-2446
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Country | US
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Telephone | 605-431-8501
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | TAMARA S WIRTZ
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Credential | MA, CCC-SLP
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Telephone | 605-431-8501
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number | 061
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License Number State | SD
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