Healthcare Provider Details

I. General information

NPI: 1104932383
Provider Name (Legal Business Name): CHARLES BENTON MCCONNELL MA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

413 N ALLUMBAUGH SUITE 103
BOISE ID
83704
US

IV. Provider business mailing address

413 N ALLUMBAUGH SUITE 103
BOISE ID
83704
US

V. Phone/Fax

Practice location:
  • Phone: 208-658-0800
  • Fax: 208-323-1894
Mailing address:
  • Phone: 208-658-0800
  • Fax: 208-323-1894

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLPCP 127
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: