Provider Demographics
NPI:1053997270
Name:RARDIN, AMY JEAN (MA/CCC)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:JEAN
Last Name:RARDIN
Suffix:
Gender:F
Credentials:MA/CCC
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:JEAN
Other - Last Name:GOHL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA/CCC
Mailing Address - Street 1:616 S JEFFERSON ST APT B
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-3271
Mailing Address - Country:US
Mailing Address - Phone:907-229-4911
Mailing Address - Fax:
Practice Address - Street 1:650 N CLEVELAND ST
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-3600
Practice Address - Country:US
Practice Address - Phone:208-882-1120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-18
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDSLP-3206235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist