MEDICARE: MS. LAURA E ROOT 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	1041C0700X	Clinical Social Worker	LCSW24443	ID

General Provider Information

NPI Number	:	1023171428
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LAURA E ROOT LCSW

Provider Business Mailing Address
First Line	:	315 N ALLUMBAUGH
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83704-9208
Country	:	US
Telephone Number	:	208-376-3546
Fax Number	:	208-376-9792

Provider Business Practice Location Address
First Line	:	315 N ALLUMBAUGH
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83704-9208
Country	:	US
Telephone Number	:	208-376-3546
Fax Number	:	208-376-9792

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

Provider Enumeration Date	:	12/18/2006
Last Update Date	:	07/08/2007

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