Basic Information
| Provider Information | |||||||||
| NPI: | 1023565603 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCOSHEN | ||||||||
| FirstName: | ELYSE | ||||||||
| MiddleName: | MARILEE | ||||||||
| NamePrefix: | |||||||||
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| Credential: | CCC/SLP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GUNDERSON | ||||||||
| OtherFirstName: | ELYSE | ||||||||
| OtherMiddleName: | MARILEE | ||||||||
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| OtherCredential: | CCC/SLP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | ESSENTIA HEALTH DULUTH CLINIC MCL2CRED | ||||||||
| Address2: | 400 EAST THIRD STREET | ||||||||
| City: | DULUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 558051951 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187864000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | ESSENTIA HEALTH ST MARY'S MEDICAL CENTER | ||||||||
| Address2: | 407 EAST THIRD STREET | ||||||||
| City: | DULUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 558051950 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187864000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2016 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 9655 | MN | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.