Healthcare Provider Details

I. General information

NPI: 1437082740
Provider Name (Legal Business Name): MATECE LYDIA DAVIS LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2026
Last Update Date: 06/05/2026
Certification Date: 06/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 W BURNSIDE AVE
CHUBBUCK ID
83202-4916
US

IV. Provider business mailing address

1701 MOUNTAIN VIEW DR
MCCAMMON ID
83250-1645
US

V. Phone/Fax

Practice location:
  • Phone: 208-238-9000
  • Fax:
Mailing address:
  • Phone: 208-851-6625
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2381218
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: