Provider Demographics
NPI:1124335302
Name:LIEF-KUSTER, REBECCA LOU (SLP)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:LOU
Last Name:LIEF-KUSTER
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4761 COFFEE LAKE RD
Mailing Address - Street 2:
Mailing Address - City:MOOSE LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55767-9207
Mailing Address - Country:US
Mailing Address - Phone:218-341-0212
Mailing Address - Fax:
Practice Address - Street 1:4761 COFFEE LAKE RD
Practice Address - Street 2:
Practice Address - City:MOOSE LAKE
Practice Address - State:MN
Practice Address - Zip Code:55767-9207
Practice Address - Country:US
Practice Address - Phone:218-341-0212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-08
Last Update Date:2010-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN00115741235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist