Provider Demographics
NPI:1760008262
Name:NORTHWEST PEDIATRIC SPEECH THERAPY, LLC
Entity Type:Organization
Organization Name:NORTHWEST PEDIATRIC SPEECH THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH-LANGUAGE PATHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:MEGAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MCMASTER-STINE
Authorized Official - Suffix:
Authorized Official - Credentials:CCC-SLP
Authorized Official - Phone:208-660-9463
Mailing Address - Street 1:1130 W HAYDEN AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-8720
Mailing Address - Country:US
Mailing Address - Phone:208-660-9463
Mailing Address - Fax:208-908-0044
Practice Address - Street 1:1130 W HAYDEN AVE STE 103
Practice Address - Street 2:
Practice Address - City:HAYDEN
Practice Address - State:ID
Practice Address - Zip Code:83835-8720
Practice Address - Country:US
Practice Address - Phone:208-660-9463
Practice Address - Fax:208-908-0044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-19
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1740793405Medicaid