Individual
NICTE-HA BANKS
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
210 W BURNSIDE AVE, CHUBBUCK, ID 83202-4916
(435) 705-3032
Mailing address
210 W BURNSIDE AVE STE A, CHUBBUCK, ID 83202-4916
Taxonomy
Speciality
Code
Description
License number
State
101YM0800X
Mental Health Counselor
Primary
LMSW-43874
ID
Other
Enumeration date
10/09/2023
Last updated
10/09/2023
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