MEDICARE: TREVOR LANCE

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	12951	ID

General Provider Information

NPI Number	:	1578401980
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TREVOR LANCE

Provider Business Mailing Address
First Line	:	254 E ST STE B
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83402-3527
Country	:	US
Telephone Number	:	208-529-1854
Fax Number	:

Provider Business Practice Location Address
First Line	:	254 E ST STE B
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83402-3527
Country	:	US
Telephone Number	:	208-529-1854
Fax Number	:

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

Provider Enumeration Date	:	03/24/2026
Last Update Date	:	03/24/2026

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Directions to “ TREVOR LANCE ” Practice Location

Language	Start Address	Practice Location

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