Provider Demographics
NPI:1942551114
Name:ESTREM, CONRAD WILLIAM (MACCC/SLP)
Entity type:Individual
Prefix:MR
First Name:CONRAD
Middle Name:WILLIAM
Last Name:ESTREM
Suffix:
Gender:M
Credentials:MACCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2131 S BONITO WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1659
Mailing Address - Country:US
Mailing Address - Phone:208-489-9500
Mailing Address - Fax:
Practice Address - Street 1:2131 S BONITO WAY
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-1659
Practice Address - Country:US
Practice Address - Phone:208-489-9500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-27
Last Update Date:2012-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDSLP-1365235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist