Healthcare Provider Details

I. General information

NPI: 1114228384
Provider Name (Legal Business Name): ROBERT ANDREW DE WALL LCPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/04/2010
Last Update Date: 10/22/2021
Certification Date: 10/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

444 HOSPITAL WAY STE 477
POCATELLO ID
83201-2744
US

IV. Provider business mailing address

65 FORDHAM ST
POCATELLO ID
83201-3418
US

V. Phone/Fax

Practice location:
  • Phone: 208-233-7832
  • Fax: 208-233-7835
Mailing address:
  • Phone: 208-317-0027
  • Fax: 208-234-2800

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLCPC-4672
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: