Basic Information
Provider Information | |||||||||
NPI: | 1578651600 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MOLINA-MEDINA | ||||||||
FirstName: | ARMIDA | ||||||||
MiddleName: | FLORES | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LCSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 190 E BANNOCK ST | ||||||||
Address2: |   | ||||||||
City: | BOISE | ||||||||
State: | ID | ||||||||
PostalCode: | 837126241 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2083818748 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3165 E GREENHURST RD | ||||||||
Address2: |   | ||||||||
City: | NAMPA | ||||||||
State: | ID | ||||||||
PostalCode: | 836868655 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2084637330 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/11/2006 | ||||||||
LastUpdateDate: | 11/16/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/16/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | LCSW-35320 | ID | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
ID | Type | State | Issuer | Description | 807358500 | 05 | ID |   | MEDICAID | 807316200 | 05 | ID |   | MEDICAID | 807353900 | 05 | ID |   | MEDICAID | 807354500 | 05 | ID |   | MEDICAID |