MEDICARE: MR. LYLE SPENCER BOURCY LCPC

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	101YP2500X	Professional Counselor	LCPC-2757	ID

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	Q3543	OTHER	ID	BLUE CROSS OF IDAHO PROVI
2	0000101364	OTHER	ID	BLUE SHIELD OF IDAHO

General Provider Information

NPI Number	:	1235130162
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. LYLE SPENCER BOURCY LCPC

Provider Business Mailing Address
First Line	:	1303 NW 16TH ST
Second Line	:	SUITE C
City	:	FRUITLAND
State	:	ID
Zip	:	83619-2263
Country	:	US
Telephone Number	:	208-250-0374
Fax Number	:	208-452-2164

Provider Business Practice Location Address
First Line	:	1303 NW 16TH ST
Second Line	:	SUITE C
City	:	FRUITLAND
State	:	ID
Zip	:	83619-2263
Country	:	US
Telephone Number	:	208-250-0374
Fax Number	:	208-452-2164

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

Provider Enumeration Date	:	08/02/2005
Last Update Date	:	07/09/2007

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Directions to “ MR. LYLE SPENCER BOURCY LCPC” Practice Location

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