Healthcare Provider Details

I. General information

NPI: 1902072986
Provider Name (Legal Business Name): SERENA DAWN HUFF CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2008
Last Update Date: 04/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1110 CALL CREEK DR STE 7
POCATELLO ID
83201-3072
US

IV. Provider business mailing address

4672 CHRISTINE ST
CHUBBUCK ID
83202-6500
US

V. Phone/Fax

Practice location:
  • Phone: 208-233-4660
  • Fax: 208-233-4262
Mailing address:
  • Phone: 208-315-4645
  • Fax: 208-233-4262

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSLP-1659
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: