Provider Demographics
NPI:1427566751
Name:DALE, DUANE
Entity type:Individual
Prefix:
First Name:DUANE
Middle Name:
Last Name:DALE
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 1:345 MEADOWLARK LN
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-7501
Mailing Address - Country:US
Mailing Address - Phone:208-301-2433
Mailing Address - Fax:
Practice Address - Street 1:700 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-3056
Practice Address - Country:US
Practice Address - Phone:208-883-1522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-22
Last Update Date:2018-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDSLP-1276235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist