Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101Y00000X | Counselor | LSW2328 | ID |
NPI | 1003006594 |
---|---|
Provider Name | Fern Campbell |
First Address | Pocatello, ID 83201-5718 |
Second Address | Pocatello, ID 83201-5100 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 31/07/2007 |
Last Update Date | 31/07/2007 |