Healthcare Provider Details

I. General information

NPI: 1790200491
Provider Name (Legal Business Name): CARLY ROMNEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2017
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 W 4TH S
REXBURG ID
83440-2319
US

IV. Provider business mailing address

2275 W BROADWAY ST STE G
IDAHO FALLS ID
83402-2902
US

V. Phone/Fax

Practice location:
  • Phone: 208-656-4017
  • Fax:
Mailing address:
  • Phone: 208-524-7400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6578
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: