Provider Demographics
NPI:1366841710
Name:IDAHO DYSPHAGIA SPECIALISTS
Entity Type:Organization
Organization Name:IDAHO DYSPHAGIA SPECIALISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH LANGUAGE PATHOLOGIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:LEAF
Authorized Official - Suffix:
Authorized Official - Credentials:MA CCC-SLP
Authorized Official - Phone:208-863-8370
Mailing Address - Street 1:1775 W STATE ST
Mailing Address - Street 2:248
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-3924
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1775 W STATE ST
Practice Address - Street 2:248
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-3924
Practice Address - Country:US
Practice Address - Phone:208-863-8370
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-21
Last Update Date:2014-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDSLP-1331235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty