Provider Demographics
NPI:1982042495
Name:REIDER, MOLLY ANNE (MA CCC-SLP/L)
Entity Type:Individual
Prefix:MRS
First Name:MOLLY
Middle Name:ANNE
Last Name:REIDER
Suffix:
Gender:F
Credentials:MA CCC-SLP/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12887 W ELMSPRING ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-1617
Mailing Address - Country:US
Mailing Address - Phone:208-995-3909
Mailing Address - Fax:
Practice Address - Street 1:207 W GEORGIA AVE
Practice Address - Street 2:SUITE 150
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-3024
Practice Address - Country:US
Practice Address - Phone:208-489-5700
Practice Address - Fax:208-489-4077
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-06
Last Update Date:2013-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDSLP-2095235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist