Healthcare Provider Details

I. General information

NPI: 1467562603
Provider Name (Legal Business Name): DOUG HULETT LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

496 A ST
IDAHO FALLS ID
83402-3617
US

IV. Provider business mailing address

566 E 13TH ST
IDAHO FALLS ID
83404-5363
US

V. Phone/Fax

Practice location:
  • Phone: 208-552-7100
  • Fax: 208-552-7101
Mailing address:
  • Phone: 208-552-7100
  • Fax: 208-552-7101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number214133
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: