| Doctor Name: | ELISA LAURA DIEDERICH |
| NPI Number: | 1376874172 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | |
| License Number: | 1102 |
| Business Practice Address: | 2400 47th Ave S Grand Forks, ND - 582013405 |
| Business Phone Number: | 7017462230 |
| Business Fax Number: | |
| Mailing Address: | 1173 Landeco Ln Apt 201, GRAND FORKS |
| State: | ND |
| Postal Code: | 582018736 |
| Phone Number: | 7013170331 |
| Fax Number: | |
| NPI Enumeration Date: | 01/19/2010 |
| NPI Last Update Date: | 01/19/2010 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 235Z00000X |
| License Number: | 1102 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | ND |
| Taxonomy Type: | Speech, Language and Hearing Service Providers |
| Taxonomy Classification: | Speech-Language Pathologist |
| Taxonomy Specialization: | |
| Taxonomy Definition: | A speech pathologist is a person qualified by a master |