Individual
LYLENA MARIE SELF
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
LCSW
Contact information
Practice address
1720 N WESTGATE DR STE 1A, BOISE, ID 83704-7164
(208) 334-6938
(208) 334-0812
Mailing address
1720 N WESTGATE DR STE 1A, BOISE, ID 83704-7164
(208) 334-6938
(208) 334-0812
Taxonomy
Speciality
Code
Description
License number
State
171M00000X
Case Manager/Care Coordinator
Primary
LCSW30738
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
LCSW-30738
BUREAU OF OCCUPATIONAL LICENSES
ID
Enumeration date
05/02/2012
Last updated
05/02/2012
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