Provider Demographics
NPI:1285080242
Name:SPEECH AND LANGUAGE STUDIO OF THE BLACK HILLS
Entity type:Organization
Organization Name:SPEECH AND LANGUAGE STUDIO OF THE BLACK HILLS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TAMARA
Authorized Official - Middle Name:S
Authorized Official - Last Name:WIRTZ
Authorized Official - Suffix:
Authorized Official - Credentials:MA, CCC-SLP
Authorized Official - Phone:605-431-8501
Mailing Address - Street 1:2040 W MAIN ST STE 209
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702-2446
Mailing Address - Country:US
Mailing Address - Phone:605-431-8501
Mailing Address - Fax:
Practice Address - Street 1:2040 W MAIN ST STE 209
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57702-2446
Practice Address - Country:US
Practice Address - Phone:605-431-8501
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-09
Last Update Date:2016-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD061235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty