Provider Demographics
NPI:1407187354
Name:HAMMOND SPEECH PATHOLOGY LLC
Entity Type:Organization
Organization Name:HAMMOND SPEECH PATHOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH/LANGUAGE PATHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:JOANN
Authorized Official - Middle Name:
Authorized Official - Last Name:HAMMOND
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:208-552-2374
Mailing Address - Street 1:3696 S HOLMES AVE
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7911
Mailing Address - Country:US
Mailing Address - Phone:208-552-2374
Mailing Address - Fax:208-524-0867
Practice Address - Street 1:1820 E 17TH ST
Practice Address - Street 2:SUITE 270
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6469
Practice Address - Country:US
Practice Address - Phone:208-552-2374
Practice Address - Fax:208-524-0867
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-15
Last Update Date:2014-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDSLP 1346235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID808038900Medicaid
ID100000104470OtherREGENCE BLUE SHIELD
IDSPF07OtherBLUE CROSS