Provider Demographics
NPI:1316977044
Name:NILSSON, DEBRA A (MS, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:DEBRA
Middle Name:A
Last Name:NILSSON
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 1:3862 SHADOW MOUNTAIN TRL
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-8283
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2377 CORONADO ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7440
Practice Address - Country:US
Practice Address - Phone:208-535-1286
Practice Address - Fax:208-535-1291
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2014-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDSLP-1231235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist