Healthcare Provider Details

I. General information

NPI: 1912374810
Provider Name (Legal Business Name): STEFNEY LAYTON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2015
Last Update Date: 08/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 LILAC ST
BLACKFOOT ID
83221-1768
US

IV. Provider business mailing address

831 WILDROSE LN
BLACKFOOT ID
83221-1678
US

V. Phone/Fax

Practice location:
  • Phone: 208-782-1322
  • Fax: 208-782-1074
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-35087
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: