Healthcare Provider Details

I. General information

NPI: 1063097053
Provider Name (Legal Business Name): TRUJILLO J AMY MRC, LPC, LVRC, CRC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/11/2021
Last Update Date: 03/11/2021
Certification Date: 03/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

314 S 450 W
HEYBURN ID
83336-8693
US

IV. Provider business mailing address

314 S 450 W
HEYBURN ID
83336-8693
US

V. Phone/Fax

Practice location:
  • Phone: 208-650-6961
  • Fax:
Mailing address:
  • Phone: 208-650-6961
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC-7738
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: