MEDICARE: AMY MAREE DAVIS LPC

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	101YM0800X	Mental Health Counselor	LPC-4765	ID

General Provider Information

NPI Number	:	1225311723
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMY MAREE DAVIS LPC

Provider Business Mailing Address
First Line	:	1276 W RIVER STREET
Second Line	:	SUITE 100
City	:	BOISE
State	:	ID
Zip	:	83702-7066
Country	:	US
Telephone Number	:	208-338-4699
Fax Number	:	208-322-4722

Provider Business Practice Location Address
First Line	:	1276 W RIVER STREET
Second Line	:	SUITE 100
City	:	BOISE
State	:	ID
Zip	:	83702-7066
Country	:	US
Telephone Number	:	208-338-4699
Fax Number	:	208-322-4722

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

Provider Enumeration Date	:	09/21/2011
Last Update Date	:	09/21/2011

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