Provider Demographics
NPI:1790757573
Name:ADAMS, IDA (MS-CCC/SLP)
Entity Type:Individual
Prefix:
First Name:IDA
Middle Name:
Last Name:ADAMS
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 1:30576 CEDAR LN
Mailing Address - Street 2:
Mailing Address - City:LE SUEUR
Mailing Address - State:MN
Mailing Address - Zip Code:56058-4346
Mailing Address - Country:US
Mailing Address - Phone:952-758-5775
Mailing Address - Fax:952-758-5778
Practice Address - Street 1:314 MAIN ST E
Practice Address - Street 2:SUITE 3
Practice Address - City:NEW PRAGUE
Practice Address - State:MN
Practice Address - Zip Code:56071-2448
Practice Address - Country:US
Practice Address - Phone:952-758-5775
Practice Address - Fax:952-758-5778
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5931235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FM93G70ADOtherMN BCBS NUMBER
MNHP54088OtherMN HEALTHPARTNERS NUMBER
MN7341712OtherMN AETNA NUMBER