Provider Demographics
NPI:1457411696
Name:FELTS, LAURI W (MS, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:LAURI
Middle Name:W
Last Name:FELTS
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 1:347 I STREET
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402
Mailing Address - Country:US
Mailing Address - Phone:208-523-2684
Mailing Address - Fax:
Practice Address - Street 1:3814 WASHINGTON PKWY
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7591
Practice Address - Country:US
Practice Address - Phone:208-529-3562
Practice Address - Fax:208-529-4064
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDSLP-1531235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID12074086OtherASHA
IDSLP-1531OtherIDAHO LICENSURE
IDSP714OtherBLUE CROSS