Individual
LARAE A MCGILLIVRAY
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MS CCCSLP
Contact information
Practice address
1104 7TH AVE S, MSUM BOX 119, MOORHEAD, MN 56563-0001
(218) 477-4639
(218) 477-4392
Mailing address
1104 7TH AVE S, MSUM BOX 119, MOORHEAD, MN 56563-0001
(218) 477-4639
(218) 477-4392
Taxonomy
Speciality
Code
Description
License number
State
235Z00000X
Speech-Language Pathologist
Primary
7234
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
18429
ND BCBS
ND
05
—
51837
—
ND
01
—
61B52MC
MN BCBS
MN
Enumeration date
09/29/2006
Last updated
07/08/2007
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