Healthcare Provider Details

I. General information

NPI: 1629931308
Provider Name (Legal Business Name): AMANDA ARIEL LAWSON LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2025
Last Update Date: 12/08/2025
Certification Date: 12/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1246 YELLOWSTONE AVE STE C3
POCATELLO ID
83201-4373
US

IV. Provider business mailing address

1069 MALIBOU ST
POCATELLO ID
83201-2813
US

V. Phone/Fax

Practice location:
  • Phone: 208-233-1276
  • Fax:
Mailing address:
  • Phone: 562-896-1683
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number8921909
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: