=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184153017
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUSAN LEIGH EARNST LCPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/05/2017
-----------------------------------------------------
Last Update Date | 08/12/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2300 S ORCHARD ST STE B
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83705-6722
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-996-3879
-----------------------------------------------------
Fax | 208-473-7272
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2300 S ORCHARD ST STE B
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83705-6722
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-996-3879
-----------------------------------------------------
Fax | 208-473-7272
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | LCPC-7794
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | LCPC-7794
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------