Basic Information
| Provider Information | |||||||||
| NPI: | 1619325594 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MILLER | ||||||||
| FirstName: | SARAH | ||||||||
| MiddleName: | VITTUM | ||||||||
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| Credential: | SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 579 | ||||||||
| Address2: | |||||||||
| City: | COCOLALLA | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838130579 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5093852763 | ||||||||
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| Practice Location | |||||||||
| Address1: | 820 ELM DR | ||||||||
| Address2: | |||||||||
| City: | ST MARIES | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838612119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082454576 | ||||||||
| FaxNumber: | 2082452138 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2016 | ||||||||
| LastUpdateDate: | 06/01/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | SLP-1935 | WA | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 05 | ID | MEDICAID | PENDING | 01 | ID | IDAHO MEDICAID | OTHER |