Provider Demographics
NPI:1407264435
Name:RICHARDS, ITXASO (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:ITXASO
Middle Name:
Last Name:RICHARDS
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 1:320 11TH AVE S
Mailing Address - Street 2:SUITE 204
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83651-5073
Mailing Address - Country:US
Mailing Address - Phone:208-466-1077
Mailing Address - Fax:
Practice Address - Street 1:320 11TH AVE S
Practice Address - Street 2:SUITE 204
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83651-5073
Practice Address - Country:US
Practice Address - Phone:208-466-1077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-22
Last Update Date:2016-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDSLP-2737235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1447427349Medicaid