Provider Demographics
NPI:1528832326
Name:ROGSTAD, THERESA
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:ROGSTAD
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 1:1053 HIGHWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:DETROIT LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:56501-4329
Mailing Address - Country:US
Mailing Address - Phone:218-234-5692
Mailing Address - Fax:
Practice Address - Street 1:1 W ELLIOT RD STE 109
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85284-1310
Practice Address - Country:US
Practice Address - Phone:480-374-4341
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-13
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP11639235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist