=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558487165
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TAMI CHRISTIANSON-LARSON M.S., CCC, SLP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/22/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 106B DIVISION AVE. N.
-----------------------------------------------------
City | CAVALIER
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58220
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-265-8080
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12481 80TH ST NE
-----------------------------------------------------
City | MILTON
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58260-9564
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-993-8485
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | 652
-----------------------------------------------------
License Number State | ND
-----------------------------------------------------