Provider Demographics
NPI:1538328760
Name:LUPER, M. LONNETTE (MS, CCC-SLP)
Entity Type:Individual
Prefix:MISS
First Name:M.
Middle Name:LONNETTE
Last Name:LUPER
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 1:743 19TH AVE E
Mailing Address - Street 2:
Mailing Address - City:JEROME
Mailing Address - State:ID
Mailing Address - Zip Code:83338-1520
Mailing Address - Country:US
Mailing Address - Phone:208-644-6468
Mailing Address - Fax:
Practice Address - Street 1:113 E AVENUE F
Practice Address - Street 2:
Practice Address - City:JEROME
Practice Address - State:ID
Practice Address - Zip Code:83338-3132
Practice Address - Country:US
Practice Address - Phone:208-324-2443
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-03
Last Update Date:2008-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDSLP-1488235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID808103700Medicaid
IDSP054OtherBLUE CROSS OF IDAHO