Provider Demographics
NPI:1336429653
Name:FISH, REBECCA RENEE
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:RENEE
Last Name:FISH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15081 WIDGEON AVE
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83607-8383
Mailing Address - Country:US
Mailing Address - Phone:208-880-3080
Mailing Address - Fax:208-454-9003
Practice Address - Street 1:15081 WIDGEON AVE
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83607-8383
Practice Address - Country:US
Practice Address - Phone:208-880-3080
Practice Address - Fax:208-454-9003
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-17
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDTSLP-2124235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist