Healthcare Provider Details

I. General information

NPI: 1023310794
Provider Name (Legal Business Name): AMY NEWSOME LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMY ITZAINA

II. Dates (important events)

Enumeration Date: 12/01/2010
Last Update Date: 05/25/2022
Certification Date: 05/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 S ASBURY ST STE 4
MOSCOW ID
83843-2243
US

IV. Provider business mailing address

530 S ASBURY ST STE 4
MOSCOW ID
83843-2243
US

V. Phone/Fax

Practice location:
  • Phone: 208-882-2566
  • Fax:
Mailing address:
  • Phone: 208-882-2566
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLMSW 25553
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: