MEDICARE: MS. DEVON AMANDA IDALSKI MS, CCC-SLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	7101005109	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	7101005109	OTHER	MI	PROFESSIONAL LICENSE

General Provider Information

NPI Number	:	1043666993
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. DEVON AMANDA IDALSKI MS, CCC-SLP

Provider Business Mailing Address
First Line	:	16461 PINE ST
Second Line	:
City	:	PRESQUE ISLE
State	:	MI
Zip	:	49777-8653
Country	:	US
Telephone Number	:	810-305-0627
Fax Number	:	989-331-6705

Provider Business Practice Location Address
First Line	:	109 N 2ND AVE STE 203
Second Line	:
City	:	ALPENA
State	:	MI
Zip	:	49707-5305
Country	:	US
Telephone Number	:	989-278-8747
Fax Number	:	989-331-6705

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/10/2016
Last Update Date	:	12/01/2022

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Directions to “ MS. DEVON AMANDA IDALSKI MS, CCC-SLP” Practice Location

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