Provider Demographics
NPI:1619325594
Name:MILLER, SARAH VITTUM (SLP)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:VITTUM
Last Name:MILLER
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:PO BOX 579
Mailing Address - Street 2:
Mailing Address - City:COCOLALLA
Mailing Address - State:ID
Mailing Address - Zip Code:83813-0579
Mailing Address - Country:US
Mailing Address - Phone:509-385-2763
Mailing Address - Fax:
Practice Address - Street 1:820 ELM DR
Practice Address - Street 2:
Practice Address - City:ST MARIES
Practice Address - State:ID
Practice Address - Zip Code:83861-2119
Practice Address - Country:US
Practice Address - Phone:208-245-4576
Practice Address - Fax:208-245-2138
Is Sole Proprietor?:No
Enumeration Date:2016-06-01
Last Update Date:2016-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WASLP-1935235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDPENDINGMedicaid
IDPENDINGOtherIDAHO MEDICAID