Basic Information
| Provider Information | |||||||||
| NPI: | 1841522646 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALLS | ||||||||
| FirstName: | LYNDSAY | ||||||||
| MiddleName: | |||||||||
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| Credential: | LSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2055 GARRETT WAY STE 1 | ||||||||
| Address2: | |||||||||
| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832015155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082361600 | ||||||||
| FaxNumber: | 2082366695 | ||||||||
| Practice Location | |||||||||
| Address1: | 2055 GARRETT WAY STE 1 | ||||||||
| Address2: | |||||||||
| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832015155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082361600 | ||||||||
| FaxNumber: | 2082366695 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2010 | ||||||||
| LastUpdateDate: | 02/03/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 30212 | ID | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.