=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235758731
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CARLA MARIE SEYLER LSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/14/2020
-----------------------------------------------------
Last Update Date | 04/14/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 427 N. 12TH STREET 427 N. 12TH STREET
-----------------------------------------------------
City | PLUMMER
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83851-8385
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-686-1449
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 388
-----------------------------------------------------
City | PLUMMER
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83851-0388
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-686-1449
-----------------------------------------------------
Fax | 208-686-5813
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | LSW-38011
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------