1982253506 NPI number — HEIDI RASMUSSEN LCSW, ADC

Table of content: HEIDI RASMUSSEN LCSW, ADC (NPI 1982253506)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982253506 NPI number — HEIDI RASMUSSEN LCSW, ADC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RASMUSSEN
Provider First Name:
HEIDI
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW, ADC
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:
1982253506
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/03/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
645 W CLARK ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
POCATELLO
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83204-3141
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-234-9361
Provider Business Mailing Address Fax Number:
208-909-2662

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
645 W CLARK ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
POCATELLO
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83204-3141
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-234-9361
Provider Business Practice Location Address Fax Number:
208-909-2662
Provider Enumeration Date:
09/06/2019

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: 101YA0400X , with the licence number:  11736 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 104100000X , with the licence number: LMSW-38989 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: 41837 , 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: 1619090628 . This is a "OPTUM" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 1619090628 . This is a "AETNA FIRST HEALTH" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 1619090628 . This is a "SELECTHEALTH" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 1619090628 . This is a "IDAHO OPTUM" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 1619090628 . This is a "AETNA" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 1619090628 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1619090628 . This is a "PACIFIC SOURCE" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 1619090628 . This is a "REGENCE" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 1619090628 . This is a "BLUE CROSS OF IDAHO" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 1619090628 . This is a "SELECT HEALTH" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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