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General NPI Number Information
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NPI Number | 1417577412
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Entity Type | Organization
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Legal Business Name | STACEY TITUS PLLC
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Dates
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Enumeration Date | 04/20/2020
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Last Update Date | 04/20/2020
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Provider Practice Location Address
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Address Line | 5440 W FRANKLIN RD STE 201
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City | BOISE
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State | ID
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Zip | 83705-6434
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Country | US
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Telephone | 208-860-2656
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Fax |
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Provider Business Mailing Address
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Address Line | 11868 W GUNSMOKE DR
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City | BOISE
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State | ID
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Zip | 83713-4753
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Country | US
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Telephone | 208-860-2656
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Fax |
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Authorized Official
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Title or Position | LICENSED CLINICAL SOCIAL WORKER
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Name | MRS. STACEY TITUS
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Credential | LCSW38145
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Telephone | 208-860-2656
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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