Healthcare Provider Details

I. General information

NPI: 1144661463
Provider Name (Legal Business Name): KRISTA MARIE GRIFFIN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2013
Last Update Date: 03/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 SHOUP AVE
IDAHO FALLS ID
83402-3657
US

IV. Provider business mailing address

725 E 600 N
FIRTH ID
83236-1205
US

V. Phone/Fax

Practice location:
  • Phone: 208-716-4372
  • Fax:
Mailing address:
  • Phone: 208-716-4372
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLMSW 33036
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-35402
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: