Provider Demographics
NPI:1043666993
Name:IDALSKI, DEVON AMANDA (MS, CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:DEVON
Middle Name:AMANDA
Last Name:IDALSKI
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16461 PINE ST
Mailing Address - Street 2:
Mailing Address - City:PRESQUE ISLE
Mailing Address - State:MI
Mailing Address - Zip Code:49777-8653
Mailing Address - Country:US
Mailing Address - Phone:810-305-0627
Mailing Address - Fax:989-331-6705
Practice Address - Street 1:109 N 2ND AVE STE 203
Practice Address - Street 2:
Practice Address - City:ALPENA
Practice Address - State:MI
Practice Address - Zip Code:49707-5305
Practice Address - Country:US
Practice Address - Phone:989-278-8747
Practice Address - Fax:989-331-6705
Is Sole Proprietor?:No
Enumeration Date:2016-05-10
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101005109235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI7101005109OtherPROFESSIONAL LICENSE