Provider Demographics
NPI:1013686054
Name:ADDISON, LAUREN ROSE (MS SLP)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:ROSE
Last Name:ADDISON
Suffix:
Gender:F
Credentials:MS SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 11TH AVE S # 155
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83651-3918
Mailing Address - Country:US
Mailing Address - Phone:208-466-1077
Mailing Address - Fax:
Practice Address - Street 1:8620 W EMERALD ST STE 100
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-4838
Practice Address - Country:US
Practice Address - Phone:208-898-1368
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-13
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDSLP-5421235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist