Provider Demographics
NPI:1730231515
Name:INDEPENDENT COMMUNICATION THERAPY
Entity type:Organization
Organization Name:INDEPENDENT COMMUNICATION THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SLP
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:K
Authorized Official - Last Name:WOOLSEY
Authorized Official - Suffix:
Authorized Official - Credentials:MS SLP
Authorized Official - Phone:701-740-5740
Mailing Address - Street 1:901 S 11TH ST
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-4449
Mailing Address - Country:US
Mailing Address - Phone:701-740-5740
Mailing Address - Fax:701-795-9760
Practice Address - Street 1:901 S 11TH ST
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-4449
Practice Address - Country:US
Practice Address - Phone:701-740-5740
Practice Address - Fax:701-795-9760
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND344235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN135H8INOtherBLUE CROSS OF MN
ND51425Medicaid
ND20526OtherBLUE CROSS OF ND