Provider Demographics
NPI:1407201312
Name:LEWIS, KIRSTEN T (MS,CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:T
Last Name:LEWIS
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 1:1906 FAIRVIEW AVE
Mailing Address - Street 2:SUITE 330
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83605-5407
Mailing Address - Country:US
Mailing Address - Phone:208-454-9223
Mailing Address - Fax:
Practice Address - Street 1:1906 FAIRVIEW AVE
Practice Address - Street 2:SUITE 330
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-5407
Practice Address - Country:US
Practice Address - Phone:208-454-9223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-28
Last Update Date:2016-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDSLP-2094235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist