Healthcare Provider Details

I. General information

NPI: 1720753460
Provider Name (Legal Business Name): HUCKLEBERRY THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2021
Last Update Date: 08/13/2021
Certification Date: 06/07/2021
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: 509-496-3317
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QH0700X
TaxonomyHearing and Speech Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SARAH NICOLE DESIMONE
Title or Position: OWNER
Credential: MS, CCC-SLP
Phone: 208-994-3757