Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XM0800X | Mental Health | OT-807 | ID |
NPI | 1417269895 |
---|---|
Provider Name | Kimberly Gail Lloyd |
First Address | Pocatello, ID 83201-5159 |
Second Address | Pocatello, ID 83201-5159 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/07/2010 |
Last Update Date | 21/05/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1376865006 | (05) | ID |