Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YP2500X | Professional Counselor | LCPC-3737 | ID |
NPI | 1003135484 |
---|---|
Provider Name | Lara Leigh Vick-Erickson |
First Address | Boise, ID 83713-0977 |
Second Address | Nampa, ID 83651-1763 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 24/05/2010 |
Last Update Date | 24/05/2010 |