Healthcare Provider Details

I. General information

NPI: 1396594628
Provider Name (Legal Business Name): BRYAN LANKFORD LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2024
Last Update Date: 05/17/2024
Certification Date: 05/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 S 4TH AVE
POCATELLO ID
83201-6404
US

IV. Provider business mailing address

1544 SARATOGA ST
POCATELLO ID
83201-2252
US

V. Phone/Fax

Practice location:
  • Phone: 208-478-9081
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number10497
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: