Provider Demographics
NPI:1699075945
Name:PROGRESSIVE THERAPY ASSOCIATES
Entity type:Organization
Organization Name:PROGRESSIVE THERAPY ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH-LANGUAGE PATHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:JODI
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:HEDSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:MS CCC-SLP
Authorized Official - Phone:701-356-7766
Mailing Address - Street 1:825 28TH ST S STE B
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-2325
Mailing Address - Country:US
Mailing Address - Phone:701-356-7766
Mailing Address - Fax:701-356-7765
Practice Address - Street 1:825 28TH ST S STE B
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-2325
Practice Address - Country:US
Practice Address - Phone:701-356-7766
Practice Address - Fax:701-356-7765
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-02
Last Update Date:2022-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND957235Z00000X
ND840235Z00000X
MN8076235Z00000X
MN8674235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN0DI79PROtherBLUE CROSS BLUE SHIELD