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NPI Code Detail

MEDICARE: KATHERINE WIDESTROM

MEDICARE: KATHERINE WIDESTROM
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
1235Z00000XSpeech-Language Pathologist7196MN

General Provider Information

NPI Number : 1699776252
Entity Type Code : Individual
Provider Name (Legal Business Name) : KATHERINE WIDESTROM
Provider Business Mailing Address
First Line : 5531 PONY AVENUE NORTH
Second Line :
City : CRYSTAL
State : MN
Zip : 55429
Country : US
Telephone Number : 763-535-9498
Fax Number :
Provider Business Practice Location Address
First Line : 4010 W 65TH ST
Second Line : SUITE 105
City : EDINA
State : MN
Zip : 55435-1721
Country : US
Telephone Number : 952-285-2840
Fax Number : 952-285-2830
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/04/2005
Last Update Date : 03/18/2010

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Directions to “ KATHERINE WIDESTROM ” 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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