Provider Demographics
NPI:1306270384
Name:HAFNER, LAREE A (SLP)
Entity type:Individual
Prefix:
First Name:LAREE
Middle Name:A
Last Name:HAFNER
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 1:115 AVENUE D
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59101-0644
Mailing Address - Country:US
Mailing Address - Phone:406-969-4770
Mailing Address - Fax:406-969-4771
Practice Address - Street 1:945 BROADWATER SQ
Practice Address - Street 2:
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59101-1634
Practice Address - Country:US
Practice Address - Phone:406-969-4770
Practice Address - Fax:406-969-4771
Is Sole Proprietor?:No
Enumeration Date:2013-08-27
Last Update Date:2013-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTSLP-SP-TMP-3073235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTSLP-SP-TMP-3073OtherPROFESSIONAL LICENSE