Provider Demographics
NPI:1417278383
Name:OFTEDAL, VIDYA H (SLP)
Entity Type:Individual
Prefix:
First Name:VIDYA
Middle Name:H
Last Name:OFTEDAL
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415A LINGENBERRY LN
Mailing Address - Street 2:
Mailing Address - City:SOLDOTNA
Mailing Address - State:AK
Mailing Address - Zip Code:99669-8041
Mailing Address - Country:US
Mailing Address - Phone:907-260-7444
Mailing Address - Fax:
Practice Address - Street 1:35105 KENAI SPUR HWY STE A
Practice Address - Street 2:
Practice Address - City:SOLDOTNA
Practice Address - State:AK
Practice Address - Zip Code:99669-7658
Practice Address - Country:US
Practice Address - Phone:907-260-7444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-15
Last Update Date:2010-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK308235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist