Healthcare Provider Details

I. General information

NPI: 1114203031
Provider Name (Legal Business Name): CHESTER C MARDIS LPC/NCC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2011
Last Update Date: 01/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

493 EASTLAND DR.
TWIN FALLS ID
83301
US

IV. Provider business mailing address

P.O. BOX 47
TWIN FALLS ID
83303
US

V. Phone/Fax

Practice location:
  • Phone: 208-732-0995
  • Fax: 208-732-0993
Mailing address:
  • Phone: 208-732-0995
  • Fax: 208-732-0993

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC4840
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: