=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457020794
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LOUIS ALEXANDER MASSOTH LCSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/09/2021
-----------------------------------------------------
Last Update Date | 09/09/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5700 E FRANKLIN RD STE 220I
-----------------------------------------------------
City | NAMPA
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83687-5065
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-889-8060
-----------------------------------------------------
Fax | 208-899-8757
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5700 E FRANKLIN RD STE 220I
-----------------------------------------------------
City | NAMPA
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83687-5065
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-889-8060
-----------------------------------------------------
Fax | 208-899-8757
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 1160
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------