=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811064801
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | J REED STODDARD MSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/29/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 SHC
-----------------------------------------------------
City | REXBURG
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83460-2020
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-496-1100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 249 S MILLHOLLOW RD
-----------------------------------------------------
City | REXBURG
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83440-2221
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-496-1100
-----------------------------------------------------
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 | LCSW-945
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------