Healthcare Provider Details

I. General information

NPI: 1528400793
Provider Name (Legal Business Name): MARILYN STANDFIELD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2013
Last Update Date: 08/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1202 E 25TH ST
IDAHO FALLS ID
83404-7072
US

IV. Provider business mailing address

1202 E 25TH ST
IDAHO FALLS ID
83404-7072
US

V. Phone/Fax

Practice location:
  • Phone: 208-520-8219
  • Fax:
Mailing address:
  • Phone: 208-520-8219
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code225CX0006X
TaxonomyOrientation and Mobility Training Rehabilitation Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: