Individual
ELISA LAURA DIEDERICH
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
2400 47TH AVE S, GRAND FORKS, ND 58201-3405
(701) 746-2230
Mailing address
1173 LANDECO LN APT 201, GRAND FORKS, ND 58201-8736
(701) 317-0331
Taxonomy
Speciality
Code
Description
License number
State
235Z00000X
Speech-Language Pathologist
Primary
1102
ND
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
54002
—
ND
Enumeration date
01/19/2010
Last updated
01/19/2010
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