Healthcare Provider Details

I. General information

NPI: 1235130162
Provider Name (Legal Business Name): LYLE SPENCER BOURCY LCPC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/02/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1303 NW 16TH ST SUITE C
FRUITLAND ID
83619-2263
US

IV. Provider business mailing address

1303 NW 16TH ST SUITE C
FRUITLAND ID
83619-2263
US

V. Phone/Fax

Practice location:
  • Phone: 208-250-0374
  • Fax: 208-452-2164
Mailing address:
  • Phone: 208-250-0374
  • Fax: 208-452-2164

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLCPC-2757
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: