MEDICARE: HAMMOND SPEECH PATHOLOGY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	SLP 1346	ID

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	100000104470	OTHER	ID	REGENCE BLUE SHIELD
3	SPF07	OTHER	ID	BLUE CROSS

General Provider Information

NPI Number	:	1407187354
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HAMMOND SPEECH PATHOLOGY LLC

Provider Business Mailing Address
First Line	:	3696 S HOLMES AVE
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83404-7911
Country	:	US
Telephone Number	:	208-552-2374
Fax Number	:	208-524-0867

Provider Business Practice Location Address
First Line	:	1820 E 17TH ST
Second Line	:	SUITE 270
City	:	IDAHO FALLS
State	:	ID
Zip	:	83404-6469
Country	:	US
Telephone Number	:	208-552-2374
Fax Number	:	208-524-0867

Authorized Official
Title or Position	:	SPEECH/LANGUAGE PATHOLOGIST
Name	:	JOANN HAMMOND
Credential	:	M.S.
Telephone Number	:	208-552-2374

Provider Enumeration Date	:	01/15/2010
Last Update Date	:	09/17/2014

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