Provider Demographics
NPI:1235449539
Name:HENDARTO, HERU (MD,MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:HERU
Middle Name:
Last Name:HENDARTO
Suffix:
Gender:M
Credentials:MD,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 1:755 JUSTIN KAY CT
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84104-1619
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:755 JUSTIN KAY CT
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84104-1619
Practice Address - Country:US
Practice Address - Phone:801-599-7471
Practice Address - Fax:801-956-0741
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-20
Last Update Date:2010-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4841650-4102235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT4841650-4102OtherSTATE SLP LISENCE