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General NPI Number Information
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NPI Number | 1467268953
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Entity Type | Organization
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Legal Business Name | LC-ADVANCED HEALTH & WELLNESS
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Dates
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Enumeration Date | 12/09/2024
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Last Update Date | 12/09/2024
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Provider Practice Location Address
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Address Line | 1428 G ST
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City | LEWISTON
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State | ID
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Zip | 83501-2031
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Country | US
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Telephone | 208-848-4140
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Fax | 208-848-4143
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Provider Business Mailing Address
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Address Line | 1428 G ST
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City | LEWISTON
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State | ID
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Zip | 83501-2031
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Country | US
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Telephone | 208-848-4140
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Fax | 208-848-4143
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Authorized Official
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Title or Position | OWNER
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Name | MR. ANTHONY BRIAN TENNY
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Credential | MSW, CADC
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Telephone | 208-816-0015
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number |
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License Number State |
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