Provider Demographics
NPI:1295265718
Name:REDDISH, SANDRA SUMMERS (MS CC SLP)
Entity type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:SUMMERS
Last Name:REDDISH
Suffix:
Gender:F
Credentials:MS CC SLP
Other - Prefix:
Other - First Name:SANDY
Other - Middle Name:
Other - Last Name:SUMMERS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS CCC SLP
Mailing Address - Street 1:3653 E SPECTRUM DR
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-5041
Mailing Address - Country:US
Mailing Address - Phone:208-206-9613
Mailing Address - Fax:
Practice Address - Street 1:36 PROFESSIONAL PLZ STE 110
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-2049
Practice Address - Country:US
Practice Address - Phone:208-359-9570
Practice Address - Fax:208-359-9580
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-18
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDSLP-1625235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty