MEDICARE: MINNESOTA STATE COLLEGES AND UNIVERSITIES

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	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1811457369
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MINNESOTA STATE COLLEGES AND UNIVERSITIES

Provider Business Mailing Address
First Line	:	150 SOUTH RD
Second Line	:	317 CLINICAL SCIENCES BUILDING
City	:	MANKATO
State	:	MN
Zip	:	56001-7046
Country	:	US
Telephone Number	:	507-389-1414
Fax Number	:	507-389-2821

Provider Business Practice Location Address
First Line	:	150 SOUTH RD
Second Line	:	116 CLINICAL SCIENCES BUILDING
City	:	MANKATO
State	:	MN
Zip	:	56001-7046
Country	:	US
Telephone Number	:	507-389-6298
Fax Number	:	507-389-2821

Authorized Official
Title or Position	:	DEPART CHAIR
Name	:	MEGAN MAHOWALD
Credential	:	PH.D. CCC-SLP
Telephone Number	:	507-389-1415

Provider Enumeration Date	:	03/21/2019
Last Update Date	:	10/24/2019

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