Healthcare Provider Details

I. General information

NPI: 1912185968
Provider Name (Legal Business Name): ROSA ANJELICA METTLER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/01/2008
Last Update Date: 07/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 W IRONWOOD DR STE 6
COEUR D ALENE ID
83814-2644
US

IV. Provider business mailing address

950 W IRONWOOD DR STE 6
COEUR D ALENE ID
83814-2644
US

V. Phone/Fax

Practice location:
  • Phone: 208-704-5401
  • Fax: 208-664-8681
Mailing address:
  • Phone: 208-704-5401
  • Fax: 208-664-8681

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLCSW34821
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: