MEDICARE: JILL DIMITRI ST

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	9503	MN

General Provider Information

NPI Number	:	1568543387
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JILL DIMITRI ST

Provider Business Mailing Address
First Line	:	150 LOST LAKE CT
Second Line	:
City	:	MAHTOMEDI
State	:	MN
Zip	:	55115-1865
Country	:	US
Telephone Number	:	309-830-6216
Fax Number	:

Provider Business Practice Location Address
First Line	:	2555 COUNTY ROAD E E # 102
Second Line	:
City	:	WHITE BEAR LAKE
State	:	MN
Zip	:	55110-4906
Country	:	US
Telephone Number	:	651-683-2953
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/18/2006
Last Update Date	:	10/02/2019

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Directions to “ JILL DIMITRI ST” Practice Location

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