Provider Demographics
NPI:1144892779
Name:BARANICK, THERESA DANIELLE (CF-SLP)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:DANIELLE
Last Name:BARANICK
Suffix:
Gender:F
Credentials:CF-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1550 JEWEL DR
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-9001
Mailing Address - Country:US
Mailing Address - Phone:651-278-0510
Mailing Address - Fax:
Practice Address - Street 1:1400 MADISON AVE STE 100AA
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-5465
Practice Address - Country:US
Practice Address - Phone:507-594-2600
Practice Address - Fax:507-594-4810
Is Sole Proprietor?:No
Enumeration Date:2021-07-13
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN518194235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist