=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700367133
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MADISON RAIN MOLINO LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/23/2018
-----------------------------------------------------
Last Update Date | 06/27/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5001 CHERRY GULCH LN
-----------------------------------------------------
City | EMMETT
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83617-5123
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-365-3437
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 967 E PARKCENTER BLVD # 1079
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83706-6721
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-633-7314
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 11939680-3501
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 43915
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------