Provider Demographics
NPI:1053626093
Name:RICHARDSON, MISTY (MS, CF-SLP)
Entity type:Individual
Prefix:MRS
First Name:MISTY
Middle Name:
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:MS, CF-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:925 S UTAH AVE
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402-3322
Mailing Address - Country:US
Mailing Address - Phone:208-542-7190
Mailing Address - Fax:208-542-7199
Practice Address - Street 1:2775 SANDY CIR
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-4828
Practice Address - Country:US
Practice Address - Phone:208-520-8488
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-14
Last Update Date:2010-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist