=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114222064
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANDREA MICHELE EMMONS LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/24/2011
-----------------------------------------------------
Last Update Date | 03/24/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 847 PARK CENTRE WAY STE. 4 CORE COUNSELING CENTER
-----------------------------------------------------
City | NAMPA
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83646
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-467-2673
-----------------------------------------------------
Fax | 208-467-4150
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 847 PARK CENTRE WAY STE. 4 CORE COUNSELING CENTER
-----------------------------------------------------
City | NAMPA
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83646
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-467-2673
-----------------------------------------------------
Fax | 208-467-4150
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | LCSW30993
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------