Provider Demographics
NPI:1003054560
Name:EATON, LORI NICOLE (LCSW)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:NICOLE
Last Name:EATON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3709 N LOCUST GROVE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-6450
Mailing Address - Country:US
Mailing Address - Phone:208-571-7100
Mailing Address - Fax:208-493-4331
Practice Address - Street 1:3709 N LOCUST GROVE RD STE 100
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-6450
Practice Address - Country:US
Practice Address - Phone:208-571-7100
Practice Address - Fax:208-493-4331
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-21
Last Update Date:2016-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW 28083104100000X
IDLCSW- 312591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806968300Medicaid
ID1041C0700XOtherTAXONOMY
ID20001460OtherPTAN