Healthcare Provider Details

I. General information

NPI: 1003054560
Provider Name (Legal Business Name): LORI NICOLE EATON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/21/2009
Last Update Date: 10/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3709 N LOCUST GROVE RD STE 100
MERIDIAN ID
83646-6450
US

IV. Provider business mailing address

3709 N LOCUST GROVE RD STE 100
MERIDIAN ID
83646-6450
US

V. Phone/Fax

Practice location:
  • Phone: 208-571-7100
  • Fax: 208-493-4331
Mailing address:
  • Phone: 208-571-7100
  • Fax: 208-493-4331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLMSW 28083
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW- 31259
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: