Provider Demographics
NPI:1588235360
Name:KINGSTROM, HANNALEE (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:HANNALEE
Middle Name:
Last Name:KINGSTROM
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 1:1857 S MILLENIUM WAY STE 120
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1510
Mailing Address - Country:US
Mailing Address - Phone:208-600-0722
Mailing Address - Fax:
Practice Address - Street 1:1857 S MILLENIUM WAY STE 120
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-1510
Practice Address - Country:US
Practice Address - Phone:208-600-0722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-02
Last Update Date:2021-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDSLP-4825235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist