Provider Demographics
NPI:1306045844
Name:GEARHART, CARISA A (MS CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:CARISA
Middle Name:A
Last Name:GEARHART
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 1:3175 GOLDFIELD DR
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-2777
Mailing Address - Country:US
Mailing Address - Phone:208-604-0287
Mailing Address - Fax:
Practice Address - Street 1:7 N 600 W
Practice Address - Street 2:
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221-5533
Practice Address - Country:US
Practice Address - Phone:208-684-9812
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-14
Last Update Date:2007-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDSLP-1608235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist