Provider Demographics
NPI:1699776252
Name:WIDESTROM, KATHERINE
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:WIDESTROM
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 1:5531 PONY AVENUE NORTH
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL
Mailing Address - State:MN
Mailing Address - Zip Code:55429
Mailing Address - Country:US
Mailing Address - Phone:763-535-9498
Mailing Address - Fax:
Practice Address - Street 1:4010 W 65TH ST
Practice Address - Street 2:SUITE 105
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-1721
Practice Address - Country:US
Practice Address - Phone:952-285-2840
Practice Address - Fax:952-285-2830
Is Sole Proprietor?:No
Enumeration Date:2005-08-04
Last Update Date:2010-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7196235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist