Healthcare Provider Details

I. General information

NPI: 1487985198
Provider Name (Legal Business Name): TAMI LYNN DIAL MA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2010
Last Update Date: 01/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 N EISENHOWER ST
MOSCOW ID
83843-9588
US

IV. Provider business mailing address

640 N EISEHOWER STREET
MOSCOW ID
83843
US

V. Phone/Fax

Practice location:
  • Phone: 208-882-6560
  • Fax:
Mailing address:
  • Phone: 208-882-6560
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSLP1447
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: