=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194179309
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMY MOSER M.S. CCC-SLP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/14/2016
-----------------------------------------------------
Last Update Date | 04/14/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7 N 600 W
-----------------------------------------------------
City | BLACKFOOT
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83221-5533
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-782-2267
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 54 S 520 W
-----------------------------------------------------
City | BLACKFOOT
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83221-6187
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-785-0886
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | SLP-2937
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------