Provider Demographics
NPI:1063087401
Name:DEACON, ELIZABETH MARIE
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:MARIE
Last Name:DEACON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16326 FERNANDO WAY W
Mailing Address - Street 2:
Mailing Address - City:ROSEMOUNT
Mailing Address - State:MN
Mailing Address - Zip Code:55068-1469
Mailing Address - Country:US
Mailing Address - Phone:920-615-4140
Mailing Address - Fax:
Practice Address - Street 1:3395 PLYMOUTH RD
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55305-3765
Practice Address - Country:US
Practice Address - Phone:952-939-0396
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-26
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN518109235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist