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General NPI Number Information
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NPI Number | 1114301181
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Entity Type | Organization
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Legal Business Name | ST. LUKE'S CHILDREN'S
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Dates
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Enumeration Date | 07/19/2015
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Last Update Date | 07/19/2015
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Provider Practice Location Address
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Address Line | 190 E BANNOCK ST
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City | BOISE
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State | ID
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Zip | 83712-6241
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Country | US
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Telephone | 208-381-2804
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Fax |
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Provider Business Mailing Address
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Address Line | 190 E BANNOCK ST
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City | BOISE
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State | ID
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Zip | 83712-6241
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | SPEECH LANGUAGE PATHOLOGIST
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Name | KRISTIN G BOOTON
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Credential | MS CCC-SLP
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Telephone | 502-693-0329
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 282NC2000X
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Taxonomy Name | Children's Hospital
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License Number | SLP-2765
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License Number State | ID
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