Provider Demographics
NPI:1275170383
Name:ABBOTT, ANGELA M (SLP)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:M
Last Name:ABBOTT
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:M
Other - Last Name:SELLS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SLP
Mailing Address - Street 1:79 N PLUMMER RD
Mailing Address - Street 2:
Mailing Address - City:STAR
Mailing Address - State:ID
Mailing Address - Zip Code:83669-5561
Mailing Address - Country:US
Mailing Address - Phone:208-391-2773
Mailing Address - Fax:
Practice Address - Street 1:79 N PLUMMER RD
Practice Address - Street 2:
Practice Address - City:STAR
Practice Address - State:ID
Practice Address - Zip Code:83669-5561
Practice Address - Country:US
Practice Address - Phone:208-391-2773
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-09
Last Update Date:2019-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDSLP-2792235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist