Provider Demographics
NPI:1073969564
Name:LONG, MILODIE MAE (SLP-CCC)
Entity Type:Individual
Prefix:MRS
First Name:MILODIE
Middle Name:MAE
Last Name:LONG
Suffix:
Gender:F
Credentials:SLP-CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 N CURTIS RD
Mailing Address - Street 2:STE. 204
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-1338
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:901 N CURTIS RD
Practice Address - Street 2:STE. 204
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-1338
Practice Address - Country:US
Practice Address - Phone:208-367-7598
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-13
Last Update Date:2016-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR15248235Z00000X
IDSLP-2909235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist