Provider Demographics
NPI:1952785172
Name:WALDRON, SHAYNA (SLP)
Entity Type:Individual
Prefix:
First Name:SHAYNA
Middle Name:
Last Name:WALDRON
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:560 MEMORIAL DR
Mailing Address - Street 2:STE C
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4070
Mailing Address - Country:US
Mailing Address - Phone:208-904-1112
Mailing Address - Fax:855-319-1499
Practice Address - Street 1:560 MEMORIAL DR
Practice Address - Street 2:STE C
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4070
Practice Address - Country:US
Practice Address - Phone:208-904-1112
Practice Address - Fax:855-319-1499
Is Sole Proprietor?:No
Enumeration Date:2015-07-17
Last Update Date:2015-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID2771235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist