Healthcare Provider Details

I. General information

NPI: 1740605112
Provider Name (Legal Business Name): TARA LZICAR LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TARA BRENNER LPC

II. Dates (important events)

Enumeration Date: 02/21/2014
Last Update Date: 07/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 S 23RD ST
BOISE ID
83702-9100
US

IV. Provider business mailing address

PO BOX 9
NAMPA ID
83653-0009
US

V. Phone/Fax

Practice location:
  • Phone: 208-344-3512
  • Fax: 208-344-4898
Mailing address:
  • Phone: 208-461-7149
  • Fax: 208-467-3391

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLCPC-6457
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: