Provider Demographics
NPI:1295579068
Name:REISWIG, ADRIENNE DEMI (AUD)
Entity type:Individual
Prefix:
First Name:ADRIENNE
Middle Name:DEMI
Last Name:REISWIG
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 N LIBERTY ST STE 400
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-8707
Mailing Address - Country:US
Mailing Address - Phone:208-336-4368
Mailing Address - Fax:208-813-1929
Practice Address - Street 1:900 N LIBERTY ST STE 400
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8707
Practice Address - Country:US
Practice Address - Phone:208-336-4368
Practice Address - Fax:208-813-1929
Is Sole Proprietor?:No
Enumeration Date:2024-06-25
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDAUD-6417231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist