Healthcare Provider Details

I. General information

NPI: 1174641450
Provider Name (Legal Business Name): LESA MCCONNEL LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 09/12/2024
Certification Date: 09/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

921 S ORCHARD ST STE 101
BOISE ID
83705-1916
US

IV. Provider business mailing address

5223 W OVERLAND RD
BOISE ID
83705-2637
US

V. Phone/Fax

Practice location:
  • Phone: 208-703-7357
  • Fax: 208-712-6778
Mailing address:
  • Phone: 208-395-1713
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCSW 1100
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLCSW 1100
License Number StateID
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLCSW 1100
License Number StateID
# 4
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW 1100
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: