MEDICARE: SPEECH PATHOLOGY ASSOCIATES, INC

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	261QH0700X	Hearing and Speech Clinic/Center	SLP-2122	ID

General Provider Information

NPI Number	:	1689954588
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPEECH PATHOLOGY ASSOCIATES, INC

Provider Business Mailing Address
First Line	:	550 AMY LN
Second Line	:
City	:	AMMON
State	:	ID
Zip	:	83406-4542
Country	:	US
Telephone Number	:	208-221-1094
Fax Number	:

Provider Business Practice Location Address
First Line	:	3715 WOODKING DR
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83404-4720
Country	:	US
Telephone Number	:	208-529-2255
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MRS. BRENDA PADRON
Credential	:	M.S., CCC-SLP
Telephone Number	:	208-221-1094

Provider Enumeration Date	:	08/23/2011
Last Update Date	:	08/23/2011

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