Healthcare Provider Details

I. General information

NPI: 1952852436
Provider Name (Legal Business Name): BETSY PACK PETERSEN LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BETSY LEANNE PACK LMSW

II. Dates (important events)

Enumeration Date: 10/19/2016
Last Update Date: 09/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2267 TETON PLZ
IDAHO FALLS ID
83404-6486
US

IV. Provider business mailing address

2267 TETON PLZ
IDAHO FALLS ID
83404-6486
US

V. Phone/Fax

Practice location:
  • Phone: 208-522-0140
  • Fax: 208-524-7335
Mailing address:
  • Phone: 208-522-0140
  • Fax: 208-524-7335

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLMSW-38030
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLMSW-38030
License Number StateID
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number10930 (LMSW)
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: