=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639385495
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STEPHEN R SHARP LCPC, NCC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/15/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 343 W 2ND N
-----------------------------------------------------
City | RIGBY
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83442-1117
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-512-2990
-----------------------------------------------------
Fax | 877-353-9156
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 343 W 2ND N
-----------------------------------------------------
City | RIGBY
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83442-1117
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-512-2990
-----------------------------------------------------
Fax | 877-353-9156
-----------------------------------------------------
=====================================================
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 | LCPC-3416
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------