Healthcare Provider Details

I. General information

NPI: 1265881601
Provider Name (Legal Business Name): SARAH DESIMONE MS, CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2016
Last Update Date: 07/14/2021
Certification Date: 07/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6101 E HIGHWAY 54 STE A
ATHOL ID
83801-6085
US

IV. Provider business mailing address

7425 E TELLUM AVE
ATHOL ID
83801-9293
US

V. Phone/Fax

Practice location:
  • Phone: 208-994-3757
  • Fax: 208-352-3921
Mailing address:
  • Phone: 208-994-3757
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberLL60758918
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSLP-4509
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: