1154836427 NPI number — BAMBI LASSEN, MSW, LCSW, PLLC

Table of content: (NPI 1154836427)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154836427 NPI number — BAMBI LASSEN, MSW, LCSW, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BAMBI LASSEN, MSW, LCSW, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154836427
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/08/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 10
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DOVER
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83825-0010
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-290-5592
Provider Business Mailing Address Fax Number:
208-263-4478

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
102 S EUCLID AVE STE 111
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANDPOINT
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83864-4916
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-263-4477
Provider Business Practice Location Address Fax Number:
208-263-4478
Provider Enumeration Date:
12/08/2017

Additional Information

Authorized Official

Authorized Official Last Name:
LASSEN
Authorized Official First Name:
BAMBI
Authorized Official Middle Name:
R.
Authorized Official Title or Position:
CLINICIAN
Authorized Official Telephone Number:
208-290-5592

Provider Taxonomy Codes

  • Taxonomy code: 104100000X , with the licence number:  29490 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1063581429 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".




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