Healthcare Provider Details

I. General information

NPI: 1669394193
Provider Name (Legal Business Name): RAEVONNE M COX
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2026
Last Update Date: 07/27/2026
Certification Date: 07/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 S 5TH AVE STE 125
POCATELLO ID
83201-6411
US

IV. Provider business mailing address

275 S 5TH AVE STE 125
POCATELLO ID
83201-6411
US

V. Phone/Fax

Practice location:
  • Phone: 406-600-7110
  • Fax:
Mailing address:
  • Phone: 406-600-7110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number4181620
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: