Healthcare Provider Details

I. General information

NPI: 1043753742
Provider Name (Legal Business Name): LARRY BEARDEN M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/29/2016
Last Update Date: 11/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

428 6TH AVE
LEWISTON ID
83501-2355
US

IV. Provider business mailing address

428 6TH AVE
LEWISTON ID
83501-2355
US

V. Phone/Fax

Practice location:
  • Phone: 208-799-6500
  • Fax: 208-799-6504
Mailing address:
  • Phone: 208-799-6500
  • Fax: 208-799-6504

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLCPC-4986
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: