Healthcare Provider Details

I. General information

NPI: 1598105462
Provider Name (Legal Business Name): JOSHUA M NIELSEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2013
Last Update Date: 06/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

353 N 4TH AVE SUITE 110
POCATELLO ID
83201-6390
US

IV. Provider business mailing address

PO BOX 4908
POCATELLO ID
83205-4908
US

V. Phone/Fax

Practice location:
  • Phone: 208-233-7832
  • Fax:
Mailing address:
  • Phone: 208-236-1600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: