Healthcare Provider Details

I. General information

NPI: 1225624281
Provider Name (Legal Business Name): MITCHELL RAY BARNEY LSMW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2020
Last Update Date: 06/12/2026
Certification Date: 06/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1820 E 17TH ST STE 115
IDAHO FALLS ID
83404-6472
US

IV. Provider business mailing address

1820 E 17TH ST STE 115
IDAHO FALLS ID
83404-6472
US

V. Phone/Fax

Practice location:
  • Phone: 208-520-7074
  • Fax: 208-970-6188
Mailing address:
  • Phone: 208-520-7074
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLMSW-41015
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLMSW-41015
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: