Provider Demographics
NPI:1538572037
Name:HERVIG, CARLEN WILLIAMS (MS CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:CARLEN
Middle Name:WILLIAMS
Last Name:HERVIG
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:PO BOX 449
Mailing Address - Street 2:
Mailing Address - City:DRIGGS
Mailing Address - State:ID
Mailing Address - Zip Code:83422-0449
Mailing Address - Country:US
Mailing Address - Phone:208-709-7868
Mailing Address - Fax:
Practice Address - Street 1:73 NORTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:VICTOR
Practice Address - State:ID
Practice Address - Zip Code:83455
Practice Address - Country:US
Practice Address - Phone:208-705-7868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-03
Last Update Date:2014-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDSLP-1112235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist