Healthcare Provider Details

I. General information

NPI: 1336690700
Provider Name (Legal Business Name): CHASSIDY RYALS LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2016
Last Update Date: 10/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1031 W SANETTA ST
NAMPA ID
83651-5047
US

IV. Provider business mailing address

1031 W SANETTA ST
NAMPA ID
83651-5047
US

V. Phone/Fax

Practice location:
  • Phone: 208-466-7443
  • Fax:
Mailing address:
  • Phone: 208-466-7443
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLMSW35537
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLSW0903002322
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLMSW095250
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: