Provider Demographics
NPI:1194065821
Name:SWANSON, SALLY ANNE (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:ANNE
Last Name:SWANSON
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:319 S MONROE ST
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-3335
Mailing Address - Country:US
Mailing Address - Phone:208-596-7753
Mailing Address - Fax:
Practice Address - Street 1:1250 IDAHO ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-1965
Practice Address - Country:US
Practice Address - Phone:208-799-5219
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-16
Last Update Date:2013-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL00003802235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist