Provider Demographics
NPI:1902099922
Name:LIGHT, ELISSA (MS SLP CCC)
Entity Type:Individual
Prefix:
First Name:ELISSA
Middle Name:
Last Name:LIGHT
Suffix:
Gender:F
Credentials:MS SLP CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 SYLVAN RD S
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55305-2820
Mailing Address - Country:US
Mailing Address - Phone:612-600-1475
Mailing Address - Fax:
Practice Address - Street 1:3025 HARBOR LN N
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55447-5119
Practice Address - Country:US
Practice Address - Phone:612-321-8957
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-22
Last Update Date:2022-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007019046235Z00000X
MN8434235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist