Healthcare Provider Details

I. General information

NPI: 1871612036
Provider Name (Legal Business Name): CARYL M FRUGOLI LCSW LPN EAP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2007
Last Update Date: 10/03/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

548 LOMAX
IDAHO FALLS ID
83401-2634
US

IV. Provider business mailing address

548 LOMAX
IDAHO FALLS ID
83401-2634
US

V. Phone/Fax

Practice location:
  • Phone: 208-524-3733
  • Fax: 208-524-3738
Mailing address:
  • Phone: 208-524-3733
  • Fax: 208-524-3738

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLCSW26736
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: