Provider Demographics
NPI:1396457453
Name:CARRELL, SUSAN A
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:A
Last Name:CARRELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5006 W OUTLOOK AVE
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83703-3515
Mailing Address - Country:US
Mailing Address - Phone:208-850-8434
Mailing Address - Fax:
Practice Address - Street 1:520 S EAGLE RD
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-6351
Practice Address - Country:US
Practice Address - Phone:208-706-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-21
Last Update Date:2022-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDSLP-1635235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist