Provider Demographics
NPI:1063758456
Name:BLACK HILLS SPEECH INC
Entity type:Organization
Organization Name:BLACK HILLS SPEECH INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH LANGUAGE PATHOLOGIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:TERRI
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:KUSSART
Authorized Official - Suffix:
Authorized Official - Credentials:MEDCCC-SLP
Authorized Official - Phone:605-390-0833
Mailing Address - Street 1:12000 NEMO RD
Mailing Address - Street 2:
Mailing Address - City:NEMO
Mailing Address - State:SD
Mailing Address - Zip Code:57759-7618
Mailing Address - Country:US
Mailing Address - Phone:605-390-0833
Mailing Address - Fax:
Practice Address - Street 1:12000 NEMO RD
Practice Address - Street 2:
Practice Address - City:NEMO
Practice Address - State:SD
Practice Address - Zip Code:57759-7618
Practice Address - Country:US
Practice Address - Phone:605-390-0833
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-12
Last Update Date:2012-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD09142861252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5837050Medicaid