Healthcare Provider Details

I. General information

NPI: 1750200614
Provider Name (Legal Business Name): ELIZABETH STEPAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LIZ STEPAN

II. Dates (important events)

Enumeration Date: 07/14/2026
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3525 MERLIN DR
IDAHO FALLS ID
83404-4952
US

IV. Provider business mailing address

1660 SHADY PINE DR
IDAHO FALLS ID
83404-8266
US

V. Phone/Fax

Practice location:
  • Phone: 208-216-9448
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2081723
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: