Provider Demographics
NPI:1104343078
Name:CODE, GREGORY
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:CODE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5372 W WATERWHEEL DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83703-3132
Mailing Address - Country:US
Mailing Address - Phone:208-996-3333
Mailing Address - Fax:
Practice Address - Street 1:5372 W WATERWHEEL DR
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83703-3132
Practice Address - Country:US
Practice Address - Phone:208-996-9333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-23
Last Update Date:2024-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDSLP-4296235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist