Healthcare Provider Details

I. General information

NPI: 1750528956
Provider Name (Legal Business Name): GARRETT LEE COBURN LCPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/11/2009
Last Update Date: 11/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13500 S. PLEASANT VALLEY RD
KUNA ID
83634
US

IV. Provider business mailing address

PO BOX 14
KUNA ID
83634-0014
US

V. Phone/Fax

Practice location:
  • Phone: 208-336-0740
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLCPC 3851
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: