MEDICARE: UNCIL GRACE JO 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	1041C0700X	Clinical Social Worker	LCSW-30053	ID

General Provider Information

NPI Number	:	1639409188
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	UNCIL GRACE JO LCSW

Provider Business Mailing Address
First Line	:	11491 W WAGON PASS CT
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83709-8565
Country	:	US
Telephone Number	:	208-345-6202
Fax Number	:

Provider Business Practice Location Address
First Line	:	2922 CLEVELAND BLVD STE 500
Second Line	:
City	:	CALDWELL
State	:	ID
Zip	:	83605-6962
Country	:	US
Telephone Number	:	208-453-1439
Fax Number	:

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

Provider Enumeration Date	:	01/06/2010
Last Update Date	:	04/01/2010

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