Provider Demographics
NPI:1649691197
Name:SIDLARUK, CARMEN MARIE (MS, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:CARMEN
Middle Name:MARIE
Last Name:SIDLARUK
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Gender:F
Credentials:MS, CCC-SLP
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Mailing Address - Street 1:775 POLE LINE RD W
Mailing Address - Street 2:SUITE 202
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-5814
Mailing Address - Country:US
Mailing Address - Phone:208-814-2570
Mailing Address - Fax:208-814-2933
Practice Address - Street 1:775 POLE LINE RD W
Practice Address - Street 2:SUITE 202
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-5814
Practice Address - Country:US
Practice Address - Phone:208-814-2570
Practice Address - Fax:208-814-2933
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-31
Last Update Date:2013-12-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IDSLP-2268235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist