Healthcare Provider Details

I. General information

NPI: 1629157797
Provider Name (Legal Business Name): JOEL BUXTON LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 11/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2635 CHANNING WAY SUITE B
IDAHO FALLS ID
83404-7518
US

IV. Provider business mailing address

PO BOX 2651
IDAHO FALLS ID
83403-2651
US

V. Phone/Fax

Practice location:
  • Phone: 208-552-0490
  • Fax: 208-552-2518
Mailing address:
  • Phone: 208-525-2090
  • Fax: 208-523-8978

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLMFT-2661
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: