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General NPI Number Information
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NPI Number | 1114228384
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Entity Type | Individual
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Provider Name | ROBERT ANDREW DE WALL LCPC
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Gender | Male
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Dates
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Enumeration Date | 11/04/2010
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Last Update Date | 10/22/2021
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Provider Practice Location Address
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Address Line | 444 HOSPITAL WAY STE 477
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City | POCATELLO
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State | ID
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Zip | 83201-2744
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Country | US
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Telephone | 208-233-7832
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Fax | 208-233-7835
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Provider Business Mailing Address
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Address Line | 65 FORDHAM ST
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City | POCATELLO
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State | ID
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Zip | 83201-3418
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Country | US
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Telephone | 208-317-0027
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Fax | 208-234-2800
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | LCPC-4672
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License Number State | ID
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