Healthcare Provider Details

I. General information

NPI: 1205667300
Provider Name (Legal Business Name): LUCINDA CHARLOTTE BISHOP DIMAGGIO BIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2024
Last Update Date: 08/09/2024
Certification Date: 08/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1257 E MULLAN AVE
OSBURN ID
83849-0820
US

IV. Provider business mailing address

PO BOX 1155
OSBURN ID
83849-1155
US

V. Phone/Fax

Practice location:
  • Phone: 208-964-3073
  • Fax:
Mailing address:
  • Phone: 208-964-3073
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: