=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811432966
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LINDA CANTRELL LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/28/2016
-----------------------------------------------------
Last Update Date | 12/28/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 427 N MAIN ST STE 101
-----------------------------------------------------
City | POCATELLO
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83204-3016
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-705-0771
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1140 N MINK CREEK RD
-----------------------------------------------------
City | POCATELLO
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83204-7250
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-705-0771
-----------------------------------------------------
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-28640
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------