Healthcare Provider Details

I. General information

NPI: 1902977929
Provider Name (Legal Business Name): CASEY PUZEY LCPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 02/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2235 E 25TH ST SUITE 290
IDAHO FALLS ID
83404-7519
US

IV. Provider business mailing address

2235 E 25TH ST SUITE 290
IDAHO FALLS ID
83404-7519
US

V. Phone/Fax

Practice location:
  • Phone: 208-201-5876
  • Fax:
Mailing address:
  • Phone: 208-201-5876
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLCPC-3231
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: