Provider Demographics
NPI:1114203031
Name:MARDIS, CHESTER C (LPC/NCC)
Entity Type:Individual
Prefix:
First Name:CHESTER
Middle Name:C
Last Name:MARDIS
Suffix:
Gender:M
Credentials:LPC/NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 47
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83303
Mailing Address - Country:US
Mailing Address - Phone:208-732-0995
Mailing Address - Fax:208-732-0993
Practice Address - Street 1:493 EASTLAND DR.
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301
Practice Address - Country:US
Practice Address - Phone:208-732-0995
Practice Address - Fax:208-732-0993
Is Sole Proprietor?:No
Enumeration Date:2011-10-24
Last Update Date:2015-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC4840101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health