=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952450058
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DAWN T. GNEITING LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/09/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1600 JOHN ADAMS PKWY SUITE 102
-----------------------------------------------------
City | IDAHO FALLS
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83401-4300
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-529-5276
-----------------------------------------------------
Fax | 208-529-6506
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3980 E 180 N
-----------------------------------------------------
City | RIGBY
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83442-5705
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-745-8780
-----------------------------------------------------
Fax | 208-745-4100
-----------------------------------------------------
=====================================================
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-960
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------