MEDICARE: MS. LYNETTA RUTH HAGLER LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	LCSW1367	ID
2	1041C0700X	Clinical Social Worker	LCSW1367	ID

General Provider Information

NPI Number	:	1316110273
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LYNETTA RUTH HAGLER LCSW

Provider Business Mailing Address
First Line	:	1277 E 17TH ST
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83404-6126
Country	:	US
Telephone Number	:	208-523-0787
Fax Number	:	208-523-3175

Provider Business Practice Location Address
First Line	:	1277 E 17TH ST
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83404-6126
Country	:	US
Telephone Number	:	208-523-0787
Fax Number	:	208-523-3175

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/10/2008
Last Update Date	:	04/10/2008

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