MEDICARE: LORI NICOLE EATON LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker	LMSW 28083	ID
2	1041C0700X	Clinical Social Worker	LCSW- 31259	ID

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	1041C0700X	OTHER	ID	TAXONOMY
3	20001460	OTHER	ID	PTAN

General Provider Information

NPI Number	:	1003054560
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LORI NICOLE EATON LCSW

Provider Business Mailing Address
First Line	:	3709 N LOCUST GROVE RD STE 100
Second Line	:
City	:	MERIDIAN
State	:	ID
Zip	:	83646-6450
Country	:	US
Telephone Number	:	208-571-7100
Fax Number	:	208-493-4331

Provider Business Practice Location Address
First Line	:	3709 N LOCUST GROVE RD STE 100
Second Line	:
City	:	MERIDIAN
State	:	ID
Zip	:	83646-6450
Country	:	US
Telephone Number	:	208-571-7100
Fax Number	:	208-493-4331

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/21/2009
Last Update Date	:	10/17/2016

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