Healthcare Provider Details

I. General information

NPI: 1346328564
Provider Name (Legal Business Name): MYDELL LEE YEAGER MS COUNSELLING
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MYDELL FISHER

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3218 OVERLAND
BOISE ID
83705
US

IV. Provider business mailing address

3218 OVERLAND
BOISE ID
83705
US

V. Phone/Fax

Practice location:
  • Phone: 208-331-3999
  • Fax:
Mailing address:
  • Phone: 208-331-3999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number51
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: