=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407238470
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CAROL HASSEBROEK SPEECH PATHOLOGY SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/25/2015
-----------------------------------------------------
Last Update Date | 10/02/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5650 W 36TH ST APT 206 #206
-----------------------------------------------------
City | ST LOUIS PARK
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55416-2543
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-618-1040
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5650 W 36TH ST APT 206 #206
-----------------------------------------------------
City | ST LOUIS PARK
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55416-2543
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-610-1040
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/SPEECH-LANGUAGE PATHOLOGIST
-----------------------------------------------------
Name | MS. CAROL ANN HASSEBROEK
-----------------------------------------------------
Credential | M.A., CCC-SLP
-----------------------------------------------------
Telephone | 612-618-1040
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | 8910
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------