Healthcare Provider Details

I. General information

NPI: 1629698170
Provider Name (Legal Business Name): MEKAYLA BISHOP LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MEKAYLA GIBSON

II. Dates (important events)

Enumeration Date: 04/24/2020
Last Update Date: 04/24/2020
Certification Date: 04/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1223 S RAILROAD AVE
SUGAR CITY ID
83448-5072
US

IV. Provider business mailing address

PO BOX 4789
POCATELLO ID
83205-4789
US

V. Phone/Fax

Practice location:
  • Phone: 208-359-0519
  • Fax: 208-359-2493
Mailing address:
  • Phone: 208-244-6437
  • Fax: 208-269-1226

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLMSW-38878
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: