MEDICARE: CONNIE R BENKE 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	101Y00000X	Counselor	LPC-3351	ID

General Provider Information

NPI Number	:	1326066077
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CONNIE R BENKE LPC

Provider Business Mailing Address
First Line	:	19222 UPPER PLEASANT RIDGE RD
Second Line	:
City	:	CALDWELL
State	:	ID
Zip	:	83607-9082
Country	:	US
Telephone Number	:	208-850-9108
Fax Number	:

Provider Business Practice Location Address
First Line	:	2922 CLEVELAND BLVD
Second Line	:	SUITE 300
City	:	CALDWELL
State	:	ID
Zip	:	83605-4436
Country	:	US
Telephone Number	:	208-459-2267
Fax Number	:

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

Provider Enumeration Date	:	07/18/2006
Last Update Date	:	07/08/2007

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