Provider Demographics
NPI:1598484263
Name:DAHLSTROM, KAIJA (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KAIJA
Middle Name:
Last Name:DAHLSTROM
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:KAIJA
Other - Middle Name:
Other - Last Name:ELENKO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, CCC-SLP
Mailing Address - Street 1:3031 S RUSSELL ST STE B
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-8523
Mailing Address - Country:US
Mailing Address - Phone:406-396-4130
Mailing Address - Fax:
Practice Address - Street 1:3031 S RUSSELL ST STE B
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-8523
Practice Address - Country:US
Practice Address - Phone:406-396-4130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-25
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTSLP-SP-LIC-11659235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist