MEDICARE: WESLEY ROBERT FARRENS LMSW

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	104100000X	Social Worker	LMSW-38649	ID

General Provider Information

NPI Number	:	1629614987
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WESLEY ROBERT FARRENS LMSW

Provider Business Mailing Address
First Line	:	855 N CAPITAL AVE STE 2
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83402-3405
Country	:	US
Telephone Number	:	208-552-0855
Fax Number	:

Provider Business Practice Location Address
First Line	:	855 N CAPITAL AVE STE 2
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83402-3405
Country	:	US
Telephone Number	:	208-552-0855
Fax Number	:

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

Provider Enumeration Date	:	11/21/2019
Last Update Date	:	12/26/2019

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