=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770267502
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRIAN HUCK, LCSW COUNSELING AND CONSULTING, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/12/2023
-----------------------------------------------------
Last Update Date | 06/19/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 172 S ACADEMY AVE STE 160
-----------------------------------------------------
City | EAGLE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83616-6564
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-494-1600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 172 S ACADEMY AVE STE 160
-----------------------------------------------------
City | EAGLE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83616-6564
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-494-1600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/THERAPIST
-----------------------------------------------------
Name | BRIAN HUCK
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 208-494-1600
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------