Provider Demographics
NPI:1669917571
Name:STAR SPEECH AND OCCUPATIONAL THERAPY LLC
Entity type:Organization
Organization Name:STAR SPEECH AND OCCUPATIONAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, SPEECH-LANGAUGE PATHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:MEARA
Authorized Official - Middle Name:
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:
Authorized Official - Credentials:MA, CCC-SLP
Authorized Official - Phone:208-391-2773
Mailing Address - Street 1:12124 W FERAMORZ LN
Mailing Address - Street 2:
Mailing Address - City:STAR
Mailing Address - State:ID
Mailing Address - Zip Code:83669-5165
Mailing Address - Country:US
Mailing Address - Phone:208-391-2773
Mailing Address - Fax:855-255-0774
Practice Address - Street 1:12222 W BRIDGER BAY DR
Practice Address - Street 2:
Practice Address - City:STAR
Practice Address - State:ID
Practice Address - Zip Code:83669-5081
Practice Address - Country:US
Practice Address - Phone:208-391-2773
Practice Address - Fax:855-255-0774
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-31
Last Update Date:2020-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDSLP2395235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty