Healthcare Provider Details

I. General information

NPI: 1013356179
Provider Name (Legal Business Name): WORD MASON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2013
Last Update Date: 06/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1503 TETON AVE
CALDWELL ID
83605-2266
US

IV. Provider business mailing address

1503 TETON AVE
CALDWELL ID
83605-2266
US

V. Phone/Fax

Practice location:
  • Phone: 208-293-5673
  • Fax:
Mailing address:
  • Phone: 208-293-5673
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. MICHAEL WOLFE
Title or Position: MANAGING MEMBER
Credential: MSW
Phone: 208-293-5673