Healthcare Provider Details

I. General information

NPI: 1265975650
Provider Name (Legal Business Name): VICTORIA WHITE EAGLE HAHN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/02/2016
Last Update Date: 05/23/2022
Certification Date: 05/23/2022
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 NumberLCSW-40439
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: