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General NPI Number Information
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NPI Number | 1194187898
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Entity Type | Individual
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Provider Name | ERIC J FIELDSTAD II LCSW
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Gender | Male
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Dates
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Enumeration Date | 03/22/2016
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Last Update Date | 02/08/2023
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Provider Practice Location Address
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Address Line | 5185 W OVERLAND RD
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City | BOISE
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State | ID
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Zip | 83705-2635
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Country | US
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Telephone | 208-918-0697
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Fax | 208-342-7584
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Provider Business Mailing Address
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Address Line | PO BOX 45581
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City | BOISE
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State | ID
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Zip | 83711-5581
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Country | US
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Telephone | 208-880-3837
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Fax |
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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 | 104100000X
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Taxonomy Name | Social Worker
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License Number | LMSW-34845
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 1041S0200X
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Taxonomy Name | School Social Worker
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License Number | LMSW-34845
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License Number State | ID
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Taxonomy #3
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | LCSW-38192
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License Number State | ID
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