Provider Demographics
NPI:1871721514
Name:FAUSETT, TINA (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:FAUSETT
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:
Other - Last Name:PIRKL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, CCC-SLP
Mailing Address - Street 1:11455 VIKING DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-7251
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11455 VIKING DR
Practice Address - Street 2:SUITE 300
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55344-7251
Practice Address - Country:US
Practice Address - Phone:952-993-2498
Practice Address - Fax:952-993-2505
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-01
Last Update Date:2009-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7620235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist