Basic Information
| Provider Information | |||||||||
| NPI: | 1194310367 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KEES | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | SLP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 820 ELM DR | ||||||||
| Address2: | |||||||||
| City: | SAINT MARIES | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838612119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082454576 | ||||||||
| FaxNumber: | 2082452138 | ||||||||
| Practice Location | |||||||||
| Address1: | 220 S DIVISION AVE | ||||||||
| Address2: | |||||||||
| City: | SANDPOINT | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838641759 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082654514 | ||||||||
| FaxNumber: | 2082633789 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2021 | ||||||||
| LastUpdateDate: | 03/09/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | SLP-1889 | ID | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 1912218488 | 05 | ID | MEDICAID | 1073718391 | 05 | ID | MEDICAID | 135055 | 01 | ID | CMS MEDICARE NUMBER | OTHER | 1194056598 | 05 | ID | MEDICAID |