Provider Demographics
NPI:1528624673
Name:CASEY'S SPECIALTY SPEECH, LLC
Entity type:Organization
Organization Name:CASEY'S SPECIALTY SPEECH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/SPEECH THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:CASEY
Authorized Official - Middle Name:
Authorized Official - Last Name:ULRICH
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CCC-SLP
Authorized Official - Phone:208-242-7377
Mailing Address - Street 1:13413 N MOONGLOW LN
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83202-5122
Mailing Address - Country:US
Mailing Address - Phone:208-242-7377
Mailing Address - Fax:
Practice Address - Street 1:611 WILSON AVE STE 6C
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-5046
Practice Address - Country:US
Practice Address - Phone:208-242-7377
Practice Address - Fax:208-417-0956
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-14
Last Update Date:2022-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1528624673Medicaid