Healthcare Provider Details

I. General information

NPI: 1336425313
Provider Name (Legal Business Name): ILA MARIE FICA LPC, NCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ILA MARIE BINGHAM

II. Dates (important events)

Enumeration Date: 10/22/2011
Last Update Date: 10/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 N 12TH AVE
POCATELLO ID
83201-4746
US

IV. Provider business mailing address

303 N 12TH AVE
POCATELLO ID
83201-4746
US

V. Phone/Fax

Practice location:
  • Phone: 208-221-6443
  • Fax:
Mailing address:
  • Phone: 208-221-6443
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLPC-4790
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: