Provider Demographics
NPI:1427243484
Name:REGENTS OF THE UNIVERSITY OF MINNESOTA
Entity type:Organization
Organization Name:REGENTS OF THE UNIVERSITY OF MINNESOTA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:DERUITER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:612-624-3322
Mailing Address - Street 1:164 PILLSBURY DR SE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55455-0279
Mailing Address - Country:US
Mailing Address - Phone:612-624-3322
Mailing Address - Fax:612-624-7586
Practice Address - Street 1:164 PILLSBURY DR SE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455-0279
Practice Address - Country:US
Practice Address - Phone:612-624-3322
Practice Address - Fax:612-624-7586
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-12
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5987231H00000X, 235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty