Basic Information
| Provider Information | |||||||||
| NPI: | 1447967385 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROBERTS | ||||||||
| FirstName: | KATIE | ||||||||
| MiddleName: | JO | ||||||||
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| OtherLastName: | ROBERTS | ||||||||
| OtherFirstName: | KATIE | ||||||||
| OtherMiddleName: | JO | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1522 BIG BEAR WAY | ||||||||
| Address2: | |||||||||
| City: | IDAHO FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 834041218 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1460 ELK CREEK DR | ||||||||
| Address2: | |||||||||
| City: | IDAHO FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 834048237 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2085351286 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2022 | ||||||||
| LastUpdateDate: | 10/31/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/31/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.