Healthcare Provider Details

I. General information

NPI: 1962376780
Provider Name (Legal Business Name): LACY JANE BEBOUT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2025
Last Update Date: 10/03/2025
Certification Date: 10/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7905 N MEADOWLARK WAY
COEUR D ALENE ID
83815-5041
US

IV. Provider business mailing address

1559 W TUALATIN DR
POST FALLS ID
83854-5186
US

V. Phone/Fax

Practice location:
  • Phone: 208-618-2709
  • Fax:
Mailing address:
  • Phone: 208-786-0676
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: