Healthcare Provider Details

I. General information

NPI: 1629211842
Provider Name (Legal Business Name): ANN MAUREEN MCCAUGHAN M.COUN, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2009
Last Update Date: 04/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 208-346-7500
  • Fax:
Mailing address:
  • Phone: 208-346-7500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number3963
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: