Provider Demographics
NPI:1104099589
Name:BOISE SPEECH AND HEARING CLINIC
Entity type:Organization
Organization Name:BOISE SPEECH AND HEARING CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH-LANGUAGE PATHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:ALESIA
Authorized Official - Middle Name:J
Authorized Official - Last Name:HITCHCOCK
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:208-376-3591
Mailing Address - Street 1:13176 W PERSIMMON LN
Mailing Address - Street 2:SUITE 120
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-1986
Mailing Address - Country:US
Mailing Address - Phone:208-376-3591
Mailing Address - Fax:208-376-3591
Practice Address - Street 1:13176 W PERSIMMON LN
Practice Address - Street 2:SUITE 120
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-1986
Practice Address - Country:US
Practice Address - Phone:208-376-3591
Practice Address - Fax:208-376-3591
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-08
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDSLP-1320235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty