Organization
DEPARTMENT OF COMMUNICATION
Active
Other names
Speech, Language Hearing Clinic, Speech, Language Hearing Clinic
Organization subpart
No
Provider details
NPI number
Authorized official
ELLEN CARTER (BILLING SUPERVISOR)
(801) 587-9447
Entity
Organization
Contact information
Practice address
417 WAKARA WAY, #1112, SALT LAKE CITY, UT 84108-1448
(801) 581-3506
Mailing address
417 WAKARA WAY, #1112, SALT LAKE CITY, UT 84108-1448
(801) 581-3506
Taxonomy
Speciality
Code
Description
License number
State
235Z00000X
Speech-Language Pathologist
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
121638400
WYOMING MEDICAID
WY
01
—
801209200
IDAH MEDICAID
ID
05
—
876000525138
—
UT
Enumeration date
09/20/2006
Last updated
06/11/2019
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