Basic Information
| Provider Information | |||||||||
| NPI: | 1154563948 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WOLERY | ||||||||
| FirstName: | BECKY | ||||||||
| MiddleName: | JEAN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3340 E. GOLDSTONE DR. | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2084528000 | ||||||||
| FaxNumber: | 2084528055 | ||||||||
| Practice Location | |||||||||
| Address1: | 910 NW 16TH ST STE 101 | ||||||||
| Address2: | |||||||||
| City: | FRUITLAND | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2084528000 | ||||||||
| FaxNumber: | 2084528055 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/25/2009 | ||||||||
| LastUpdateDate: | 07/23/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | LCSW-30777 | ID | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 104100000X | LMSW-28988 | ID | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.