Provider Demographics
NPI:1417012410
Name:MENDEZ-SHAW, KATHIE CLAIRE (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KATHIE
Middle Name:CLAIRE
Last Name:MENDEZ-SHAW
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:KATHIE
Other - Middle Name:CLAIRE
Other - Last Name:MENDEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CCC-SLP
Mailing Address - Street 1:2714 ARLINGTON AVE
Mailing Address - Street 2:APT 201
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83605-7123
Mailing Address - Country:US
Mailing Address - Phone:208-890-4023
Mailing Address - Fax:
Practice Address - Street 1:890 N COLE RD
Practice Address - Street 2:SUITE A
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8638
Practice Address - Country:US
Practice Address - Phone:208-323-8888
Practice Address - Fax:208-323-8889
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDSLP-1419235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
10000554OtherASHA