MEDICARE: MRS. LAURI W. FELTS 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	SLP-1531	ID

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	12074086	OTHER	ID	ASHA
2	SLP-1531	OTHER	ID	IDAHO LICENSURE
3	SP714	OTHER	ID	BLUE CROSS

General Provider Information

NPI Number	:	1457411696
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LAURI W. FELTS MS, CCC-SLP

Provider Business Mailing Address
First Line	:	347 I STREET
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83402
Country	:	US
Telephone Number	:	208-523-2684
Fax Number	:

Provider Business Practice Location Address
First Line	:	3814 WASHINGTON PKWY
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83404-7591
Country	:	US
Telephone Number	:	208-529-3562
Fax Number	:	208-529-4064

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

Provider Enumeration Date	:	12/11/2006
Last Update Date	:	07/08/2007

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Directions to “ MRS. LAURI W. FELTS MS, CCC-SLP” Practice Location

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