1295265718 NPI number — MRS. SANDRA SUMMERS REDDISH MS CC SLP

Table of content: MRS. SANDRA SUMMERS REDDISH MS CC SLP (NPI 1295265718)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295265718 NPI number — MRS. SANDRA SUMMERS REDDISH MS CC SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
REDDISH
Provider First Name:
SANDRA
Provider Middle Name:
SUMMERS
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MS CC SLP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SUMMERS
Provider Other First Name:
SANDY
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MS CCC SLP
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1295265718
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3653 E SPECTRUM DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
IDAHO FALLS
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83401-5041
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-206-9613
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
36 PROFESSIONAL PLZ STE 110
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
REXBURG
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83440-2049
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-359-9570
Provider Business Practice Location Address Fax Number:
208-359-9580
Provider Enumeration Date:
06/18/2017

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  SLP-1625 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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