1306280003 NPI number — MRS. RENAE MICHELLE SUAREZ LMSW

Table of content: MRS. RENAE MICHELLE SUAREZ LMSW (NPI 1306280003)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306280003 NPI number — MRS. RENAE MICHELLE SUAREZ LMSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SUAREZ
Provider First Name:
RENAE
Provider Middle Name:
MICHELLE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LMSW
Provider Gender Code:
F

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:
1306280003
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/24/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2235 E 25TH ST
Provider Second Line Business Mailing Address:
SUITE 185
Provider Business Mailing Address City Name:
IDAHO FALLS
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83404-7519
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-390-1147
Provider Business Mailing Address Fax Number:
208-552-8847

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2235 E 25TH ST
Provider Second Line Business Practice Location Address:
SUITE 185
Provider Business Practice Location Address City Name:
IDAHO FALLS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83404-7519
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-390-1147
Provider Business Practice Location Address Fax Number:
208-552-8847
Provider Enumeration Date:
04/24/2013

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: 104100000X , with the licence number:  LMSW-32842 , 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)





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