=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962813253
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RUSSELL LYNN VOLLMER LCSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/08/2014
-----------------------------------------------------
Last Update Date | 03/06/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 215 E 50 S STE 5
-----------------------------------------------------
City | MALAD CITY
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83252-2300
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-766-2365
-----------------------------------------------------
Fax | 208-766-2364
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2672 N 3100 W
-----------------------------------------------------
City | MALAD CITY
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83252-6519
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-637-9813
-----------------------------------------------------
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 | 286822-3501
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | LCSW-36911
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | LSW-28623
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 286822-3501
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------