Healthcare Provider Details

I. General information

NPI: 1891661914
Provider Name (Legal Business Name): MARIAH DARLENE LIGNELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2025
Last Update Date: 12/05/2025
Certification Date: 12/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1908 JENNIE LEE DR
IDAHO FALLS ID
83404-6159
US

IV. Provider business mailing address

3647 E BATE ST APT 4
IDAHO FALLS ID
83401-6628
US

V. Phone/Fax

Practice location:
  • Phone: 208-932-7048
  • Fax:
Mailing address:
  • Phone: 208-932-7048
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number4971383
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: