Healthcare Provider Details

I. General information

NPI: 1679313910
Provider Name (Legal Business Name): STACY LYNN YEAGER LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2024
Last Update Date: 05/24/2024
Certification Date: 05/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 S 11TH ST STE 3
COEUR D ALENE ID
83814-4000
US

IV. Provider business mailing address

5796 N MORLEAU LN
COEUR D ALENE ID
83815-0424
US

V. Phone/Fax

Practice location:
  • Phone: 208-930-1275
  • Fax: 208-930-0330
Mailing address:
  • Phone: 208-660-5382
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number45187
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: