Individual
AUTUMN KALLOCK
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
1420 4TH AVE NW, EAST GRAND FORKS, MN 56721-1522
(218) 773-3494
Mailing address
2951 S 34TH ST, GRAND FORKS, ND 58201-6061
(701) 772-3851
Taxonomy
Speciality
Code
Description
License number
State
235Z00000X
Speech-Language Pathologist
Primary
2656
ND
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2656
STATE SLP LICENSE
ND
Enumeration date
07/01/2024
Last updated
04/14/2026
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