Healthcare Provider Details

I. General information

NPI: 1285671677
Provider Name (Legal Business Name): EVELYN HUOT LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: EVELYN MALLEA LCSW

II. Dates (important events)

Enumeration Date: 06/02/2006
Last Update Date: 02/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1740 E 17TH ST
IDAHO FALLS ID
83404-6375
US

IV. Provider business mailing address

1899 VIRGINIA AVE
IDAHO FALLS ID
83404-6208
US

V. Phone/Fax

Practice location:
  • Phone: 208-522-8725
  • Fax: 208-522-8725
Mailing address:
  • Phone: 208-731-6302
  • Fax: 208-522-8725

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW 779
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: