Provider Demographics
NPI:1750798526
Name:DOLEZAL, LAURA (CCC/SLP)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:DOLEZAL
Suffix:
Gender:F
Credentials:CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:ID
Mailing Address - Zip Code:83421-0001
Mailing Address - Country:US
Mailing Address - Phone:208-624-3794
Mailing Address - Fax:
Practice Address - Street 1:859 S YELLOWSTONE HWY
Practice Address - Street 2:SUITE 1702
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-5293
Practice Address - Country:US
Practice Address - Phone:208-351-5791
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-14
Last Update Date:2014-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDSLP-1443235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist