=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902307457
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAUREL JANE SAPP LMSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/21/2018
-----------------------------------------------------
Last Update Date | 02/21/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 314 BADIOLA ST
-----------------------------------------------------
City | CALDWELL
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83605-4389
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-454-8389
-----------------------------------------------------
Fax | 208-454-8404
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 723 ANTELOPE WAY
-----------------------------------------------------
City | CALDWELL
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83607-1517
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-364-1446
-----------------------------------------------------
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 | LMSW-37308
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------