Provider Demographics
NPI:1699111351
Name:KINSELLA, CASEY DIANNE (SLP)
Entity type:Individual
Prefix:
First Name:CASEY
Middle Name:DIANNE
Last Name:KINSELLA
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3169 S BOWN WAY
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-5400
Mailing Address - Country:US
Mailing Address - Phone:208-433-9152
Mailing Address - Fax:208-344-4752
Practice Address - Street 1:3169 S BOWN WAY
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-5400
Practice Address - Country:US
Practice Address - Phone:208-433-9152
Practice Address - Fax:208-344-4752
Is Sole Proprietor?:No
Enumeration Date:2013-05-21
Last Update Date:2013-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDTSLP2392235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist