MEDICARE: SPEECH AND LANGUAGE STUDIO OF THE BLACK HILLS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	061	SD

General Provider Information

NPI Number	:	1285080242
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPEECH AND LANGUAGE STUDIO OF THE BLACK HILLS

Provider Business Mailing Address
First Line	:	2040 W MAIN ST STE 209
Second Line	:
City	:	RAPID CITY
State	:	SD
Zip	:	57702-2446
Country	:	US
Telephone Number	:	605-431-8501
Fax Number	:

Provider Business Practice Location Address
First Line	:	2040 W MAIN ST STE 209
Second Line	:
City	:	RAPID CITY
State	:	SD
Zip	:	57702-2446
Country	:	US
Telephone Number	:	605-431-8501
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	TAMARA S WIRTZ
Credential	:	MA, CCC-SLP
Telephone Number	:	605-431-8501

Provider Enumeration Date	:	05/09/2016
Last Update Date	:	05/09/2016

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Directions to “SPEECH AND LANGUAGE STUDIO OF THE BLACK HILLS ” Practice Location

Language	Start Address	Practice Location

These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

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