MEDICARE: BETHANY RENSTROM CCC-SLP

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	8209	MN

General Provider Information

NPI Number	:	1619177946
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BETHANY RENSTROM CCC-SLP

Provider Business Mailing Address
First Line	:	6126 JONATHAN LN NW
Second Line	:
City	:	ROCHESTER
State	:	MN
Zip	:	55901-5545
Country	:	US
Telephone Number	:	651-335-8159
Fax Number	:

Provider Business Practice Location Address
First Line	:	6126 JONATHAN LN NW
Second Line	:
City	:	ROCHESTER
State	:	MN
Zip	:	55901-5545
Country	:	US
Telephone Number	:	651-335-8159
Fax Number	:

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

Provider Enumeration Date	:	07/24/2007
Last Update Date	:	04/02/2021

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Directions to “ BETHANY RENSTROM CCC-SLP” Practice Location

Language	Start Address	Practice Location

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