Provider Demographics
NPI:1780413294
Name:MODERN SPEECH AND MYOFUNCTIONAL THERAPY, LLC
Entity type:Organization
Organization Name:MODERN SPEECH AND MYOFUNCTIONAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH PATHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:ALLISON
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHMIDT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-918-1466
Mailing Address - Street 1:1036 E IRON EAGLE DR STE 108
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-6558
Mailing Address - Country:US
Mailing Address - Phone:208-918-1466
Mailing Address - Fax:
Practice Address - Street 1:1036 E IRON EAGLE DR STE 108
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-6558
Practice Address - Country:US
Practice Address - Phone:208-918-1466
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-01
Last Update Date:2025-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty