Healthcare Provider Details

I. General information

NPI: 1164091559
Provider Name (Legal Business Name): ROGER EVENSON LCSW-44535
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2021
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

951 E PLAZA DR STE 150
EAGLE ID
83616-6567
US

IV. Provider business mailing address

3076 N FIVE MILE RD
BOISE ID
83713-5215
US

V. Phone/Fax

Practice location:
  • Phone: 208-938-2836
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLMSW-40940
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-44535
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: