MEDICARE: LYLENA MARIE SELF 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	171M00000X	Case Manager/Care Coordinator	LCSW30738	ID

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	LCSW-30738	OTHER	ID	BUREAU OF OCCUPATIONAL LICENSES

General Provider Information

NPI Number	:	1295093789
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LYLENA MARIE SELF LCSW

Provider Business Mailing Address
First Line	:	1720 N WESTGATE DR STE 1A
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83704-7164
Country	:	US
Telephone Number	:	208-334-6938
Fax Number	:	208-334-0812

Provider Business Practice Location Address
First Line	:	1720 N WESTGATE DR STE 1A
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83704-7164
Country	:	US
Telephone Number	:	208-334-6938
Fax Number	:	208-334-0812

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

Provider Enumeration Date	:	05/02/2012
Last Update Date	:	05/02/2012

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