Doctor Name: | KATHERINE WIDESTROM |
NPI Number: | 1699776252 |
Entity Type Code: | Individual (1) |
Gender: | F |
Credentials: | |
License Number: | 7196 |
Business Practice Address: | 4010 W 65th St Suite 105 Edina, MN - 554351721 |
Business Phone Number: | 9522852840 |
Business Fax Number: | 9522852830 |
Mailing Address: | 5531 Pony Avenue North, CRYSTAL |
State: | MN |
Postal Code: | 55429 |
Phone Number: | 7635359498 |
Fax Number: | |
NPI Enumeration Date: | 08/04/2005 |
NPI Last Update Date: | 03/18/2010 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 235Z00000X |
License Number: | 7196 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | MN |
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 |