Basic Information
| Provider Information | |||||||||
| NPI: | 1295265718 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REDDISH | ||||||||
| FirstName: | SANDRA | ||||||||
| MiddleName: | SUMMERS | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MS CC SLP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SUMMERS | ||||||||
| OtherFirstName: | SANDY | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | MS CCC SLP | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3653 E SPECTRUM DR | ||||||||
| Address2: | |||||||||
| City: | IDAHO FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 834015041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082069613 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 36 PROFESSIONAL PLZ STE 110 | ||||||||
| Address2: | |||||||||
| City: | REXBURG | ||||||||
| State: | ID | ||||||||
| PostalCode: | 834402049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083599570 | ||||||||
| FaxNumber: | 2083599580 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2017 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | SLP-1625 | ID | Y | 193400000X SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.