Provider Demographics
NPI:1538882592
Name:PRESCOTT, SARA RAELI (MS, CF-SLP)
Entity type:Individual
Prefix:MRS
First Name:SARA
Middle Name:RAELI
Last Name:PRESCOTT
Suffix:
Gender:F
Credentials:MS, CF-SLP
Other - Prefix:
Other - First Name:RAELI
Other - Middle Name:
Other - Last Name:PRESCOTT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS, CF-SLP
Mailing Address - Street 1:113 MAIN ST N
Mailing Address - Street 2:UNIT 182
Mailing Address - City:KIMBERLY
Mailing Address - State:ID
Mailing Address - Zip Code:83341-2002
Mailing Address - Country:US
Mailing Address - Phone:208-904-3500
Mailing Address - Fax:208-268-3878
Practice Address - Street 1:113 MAIN ST N
Practice Address - Street 2:UNIT 182
Practice Address - City:KIMBERLY
Practice Address - State:ID
Practice Address - Zip Code:83341-2002
Practice Address - Country:US
Practice Address - Phone:208-904-3500
Practice Address - Fax:208-268-3878
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-23
Last Update Date:2022-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDTSLP-5465235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDIDTPID015531Medicaid