=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083623391
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANDREA L MASOM LCPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/05/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 106 E 3RD ST SUITE 2B
-----------------------------------------------------
City | MOSCOW
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83843-2970
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-882-1289
-----------------------------------------------------
Fax | 208-882-8406
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 106 E 3RD ST SUITE 2B
-----------------------------------------------------
City | MOSCOW
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83843-2970
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-882-1289
-----------------------------------------------------
Fax | 208-882-8406
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | LCPC#3017
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------