Provider Demographics
NPI:1962741843
Name:BLADE, TRISTA N (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:TRISTA
Middle Name:N
Last Name:BLADE
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:TRISTA
Other - Middle Name:N
Other - Last Name:DAU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, CCC-SLP
Mailing Address - Street 1:14130 23RD AVENUE NORTH
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55447-4904
Mailing Address - Country:US
Mailing Address - Phone:763-383-7666
Mailing Address - Fax:763-383-6013
Practice Address - Street 1:14130 23RD AVENUE NORTH
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55447-4904
Practice Address - Country:US
Practice Address - Phone:763-383-7666
Practice Address - Fax:763-383-6013
Is Sole Proprietor?:No
Enumeration Date:2013-02-12
Last Update Date:2016-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9052235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist