MEDICARE: MS. PHYLLIS ROSE NODLER 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	101YM0800X	Mental Health Counselor	LCPC-2984	ID

General Provider Information

NPI Number	:	1295983443
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. PHYLLIS ROSE NODLER LCPC

Provider Business Mailing Address
First Line	:	3709 N LOCUST GROVE RD STE 150
Second Line	:
City	:	MERIDIAN
State	:	ID
Zip	:	83646-5924
Country	:	US
Telephone Number	:	208-577-7634
Fax Number	:	208-378-8389

Provider Business Practice Location Address
First Line	:	3709 N LOCUST GROVE RD STE 150
Second Line	:
City	:	MERIDIAN
State	:	ID
Zip	:	83646-5924
Country	:	US
Telephone Number	:	208-577-7634
Fax Number	:	208-378-8389

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

Provider Enumeration Date	:	08/29/2008
Last Update Date	:	02/24/2011

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