Healthcare Provider Details

I. General information

NPI: 1447523105
Provider Name (Legal Business Name): ROBERT ANDREW SMITHSON LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/10/2012
Last Update Date: 02/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1334 MILLER AVE
BURLEY ID
83318-1729
US

IV. Provider business mailing address

608 S 125 LN W
RUPERT ID
83350-9660
US

V. Phone/Fax

Practice location:
  • Phone: 208-312-3648
  • Fax:
Mailing address:
  • Phone: 208-312-3648
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLMSW-31488
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: