Healthcare Provider Details

I. General information

NPI: 1740136811
Provider Name (Legal Business Name): ETHAN BRYAN BOOKER LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2026
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1302 E 17TH ST
IDAHO FALLS ID
83404-6270
US

IV. Provider business mailing address

678 FOSTER DR
IDAHO FALLS ID
83401-5243
US

V. Phone/Fax

Practice location:
  • Phone: 208-542-9919
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6171695
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6171695
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: