Healthcare Provider Details

I. General information

NPI: 1679094940
Provider Name (Legal Business Name): CASEY MALIA VINCENT LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2017
Last Update Date: 10/05/2020
Certification Date: 10/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

740 MCKINLEY AVE
KELLOGG ID
83837-2693
US

IV. Provider business mailing address

PO BOX 1387
HAYDEN ID
83835-1387
US

V. Phone/Fax

Practice location:
  • Phone: 208-783-1267
  • Fax:
Mailing address:
  • Phone: 208-415-0299
  • Fax: 208-625-2070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLMSW-36778
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number36778
License Number StateID
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number40088
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: