MEDICARE: EMMETT FAMILY SERVICES, LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number
1	104100000X	Social Worker
2	251S00000X	Community/Behavioral Health Agency	NA
3	363L00000X	Nurse Practitioner
4	1041C0700X	Clinical Social Worker

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	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
7	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1225107923
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EMMETT FAMILY SERVICES, LLC

Provider Business Mailing Address
First Line	:	2007 E QUAIL RUN RD
Second Line	:	SUITE 1
City	:	EMMETT
State	:	ID
Zip	:	83617-5059
Country	:	US
Telephone Number	:	208-365-5445
Fax Number	:	208-365-6226

Provider Business Practice Location Address
First Line	:	2007 E QUAIL RUN RD
Second Line	:	SUITE 1
City	:	EMMETT
State	:	ID
Zip	:	83617-5059
Country	:	US
Telephone Number	:	208-365-5445
Fax Number	:	208-365-6226

Authorized Official
Title or Position	:	CO-OWNER
Name	:	MR. MICHAEL S LEE
Credential	:	LCSW
Telephone Number	:	208-365-5445

Provider Enumeration Date	:	11/07/2006
Last Update Date	:	09/28/2010

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Directions to “EMMETT FAMILY SERVICES, LLC ” Practice Location

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