1235130162 NPI number — MR. LYLE SPENCER BOURCY LCPC

Table of content: MR. LYLE SPENCER BOURCY LCPC (NPI 1235130162)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235130162 NPI number — MR. LYLE SPENCER BOURCY LCPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOURCY
Provider First Name:
LYLE
Provider Middle Name:
SPENCER
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
LCPC
Provider Gender Code:
M

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:
1235130162
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1303 NW 16TH ST
Provider Second Line Business Mailing Address:
SUITE C
Provider Business Mailing Address City Name:
FRUITLAND
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83619-2263
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-250-0374
Provider Business Mailing Address Fax Number:
208-452-2164

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1303 NW 16TH ST
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
FRUITLAND
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83619-2263
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-250-0374
Provider Business Practice Location Address Fax Number:
208-452-2164
Provider Enumeration Date:
08/02/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  LCPC-2757 , 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: Q3543 . This is a "BLUE CROSS OF IDAHO PROVI" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 0000101364 . This is a "BLUE SHIELD OF IDAHO" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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