Healthcare Provider Details

I. General information

NPI: 1447956966
Provider Name (Legal Business Name): MIRA LEE NIELSON LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2023
Last Update Date: 12/10/2024
Certification Date: 12/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 W 4TH S
REXBURG ID
83440-2319
US

IV. Provider business mailing address

635 LINCOLN DR
IDAHO FALLS ID
83401-4156
US

V. Phone/Fax

Practice location:
  • Phone: 208-656-4017
  • Fax:
Mailing address:
  • Phone: 530-566-4117
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number8241727
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: