MEDICARE: MS. MARY THERESA PIERCE 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	1041C0700X	Clinical Social Worker	LCSW-24710	ID
2	1041C0700X	Clinical Social Worker	LCSW24710	ID

General Provider Information

NPI Number	:	1366556128
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARY THERESA PIERCE LCSW

Provider Business Mailing Address
First Line	:	2425 HAGUE RD
Second Line	:
City	:	MIDVALE
State	:	ID
Zip	:	83645-5111
Country	:	US
Telephone Number	:	208-919-5067
Fax Number	:

Provider Business Practice Location Address
First Line	:	6126 W STATE ST
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83703-2741
Country	:	US
Telephone Number	:	208-919-5067
Fax Number	:

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

Provider Enumeration Date	:	08/18/2006
Last Update Date	:	07/04/2023

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