Basic Information
| Provider Information | |||||||||
| NPI: | 1891953519 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SPEECH AND LANGUAGE CLINIC, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1275 SOUTH HIGHLINE DRIVE | ||||||||
| Address2: | |||||||||
| City: | IDAHO FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086041286 | ||||||||
| FaxNumber: | 2085351291 | ||||||||
| Practice Location | |||||||||
| Address1: | 1619 CURLEW DR STE 5 | ||||||||
| Address2: | |||||||||
| City: | AMMON | ||||||||
| State: | ID | ||||||||
| PostalCode: | 834064719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2085351286 | ||||||||
| FaxNumber: | 2085351291 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/29/2008 | ||||||||
| LastUpdateDate: | 03/28/2022 | ||||||||
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| AuthorizedOfficialLastName: | DAHLBERG | ||||||||
| AuthorizedOfficialFirstName: | MICHELLE | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER, SPEECH PATHOLOGIST | ||||||||
| AuthorizedOfficialTelephone: | 2086041286 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | M.ED., CCC-SLP | ||||||||
| NPICertificationDate: | 03/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | SLP-1147 | ID | Y | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.