Provider Demographics
NPI:1124563739
Name:BISTRICEANU, OCTAVIAN (LMSW)
Entity Type:Individual
Prefix:MR
First Name:OCTAVIAN
Middle Name:
Last Name:BISTRICEANU
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:361 W WHITETAIL CT
Mailing Address - Street 2:
Mailing Address - City:KUNA
Mailing Address - State:ID
Mailing Address - Zip Code:83634-3199
Mailing Address - Country:US
Mailing Address - Phone:208-409-2258
Mailing Address - Fax:
Practice Address - Street 1:1550 N CRESTMONT DR
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-2184
Practice Address - Country:US
Practice Address - Phone:208-288-4200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-05
Last Update Date:2017-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker