MEDICARE: MISS M. LONNETTE LUPER 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-1488	ID

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	SP054	OTHER	ID	BLUE CROSS OF IDAHO

General Provider Information

NPI Number	:	1538328760
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS M. LONNETTE LUPER MS, CCC-SLP

Provider Business Mailing Address
First Line	:	743 19TH AVE E
Second Line	:
City	:	JEROME
State	:	ID
Zip	:	83338-1520
Country	:	US
Telephone Number	:	208-644-6468
Fax Number	:

Provider Business Practice Location Address
First Line	:	113 E AVENUE F
Second Line	:
City	:	JEROME
State	:	ID
Zip	:	83338-3132
Country	:	US
Telephone Number	:	208-324-2443
Fax Number	:

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

Provider Enumeration Date	:	06/03/2008
Last Update Date	:	09/23/2008

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Directions to “ MISS M. LONNETTE LUPER MS, CCC-SLP” Practice Location

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