Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 104100000X | Social Worker | LMSW-41110 | ID |
NPI | 1003585464 |
---|---|
Provider Name | Lisa Melendy |
First Address | Meridian, ID 83642-4474 |
Second Address | Boise, ID 83704-9001 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/09/2021 |
Last Update Date | 09/09/2021 |