Healthcare Provider Details

I. General information

NPI: 1972988517
Provider Name (Legal Business Name): ASHLEY VARGAS LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2015
Last Update Date: 07/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1352 E CENTER ST STE A
POCATELLO ID
83201-4773
US

IV. Provider business mailing address

PO BOX 4789
POCATELLO ID
83205-4789
US

V. Phone/Fax

Practice location:
  • Phone: 208-233-2025
  • Fax: 208-233-2178
Mailing address:
  • Phone: 208-233-2025
  • Fax: 208-233-2178

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC-5925
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: