Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 104100000X | Social Worker | 36722 | ID |
NPI | 1003327610 |
---|---|
Provider Name | Mackenzie Bryant Garrison |
First Address | Lewiston, ID 83501-1930 |
Second Address | Lewiston, ID 83501-1930 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/10/2017 |
Last Update Date | 23/10/2017 |