Provider Demographics
NPI:1164107942
Name:BLACKHAM, HEIDI (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:
Last Name:BLACKHAM
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13147 S BILSTON LN
Mailing Address - Street 2:
Mailing Address - City:HERRIMAN
Mailing Address - State:UT
Mailing Address - Zip Code:84096-2173
Mailing Address - Country:US
Mailing Address - Phone:224-625-0633
Mailing Address - Fax:
Practice Address - Street 1:13147 S BILSTON LN
Practice Address - Street 2:
Practice Address - City:HERRIMAN
Practice Address - State:UT
Practice Address - Zip Code:84096-2173
Practice Address - Country:US
Practice Address - Phone:224-625-0633
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-19
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist