Provider Demographics
NPI:1720753460
Name:HUCKLEBERRY THERAPY LLC
Entity Type:Organization
Organization Name:HUCKLEBERRY THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:DESIMONE
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CCC-SLP
Authorized Official - Phone:208-994-3757
Mailing Address - Street 1:7425 E TELLUM AVE
Mailing Address - Street 2:
Mailing Address - City:ATHOL
Mailing Address - State:ID
Mailing Address - Zip Code:83801-9293
Mailing Address - Country:US
Mailing Address - Phone:509-496-3317
Mailing Address - Fax:
Practice Address - Street 1:6101 E HIGHWAY 54
Practice Address - Street 2:STE A
Practice Address - City:ATHOL
Practice Address - State:ID
Practice Address - Zip Code:83801-6085
Practice Address - Country:US
Practice Address - Phone:208-994-3757
Practice Address - Fax:208-352-3921
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-13
Last Update Date:2021-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
No261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and SpeechGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID016962Medicaid