Healthcare Provider Details

I. General information

NPI: 1184969578
Provider Name (Legal Business Name): MARY IRENE MCGINNIS LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2012
Last Update Date: 12/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2311 PARK AVE UNIT 3 SUITE 12
BURLEY ID
83318-2170
US

IV. Provider business mailing address

401 E 6TH ST
RUPERT ID
83350-1723
US

V. Phone/Fax

Practice location:
  • Phone: 208-678-3555
  • Fax:
Mailing address:
  • Phone: 208-670-0027
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLMSW24487
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: