Provider Demographics
NPI:1154836427
Name:BAMBI LASSEN, MSW, LCSW, PLLC
Entity Type:Organization
Organization Name:BAMBI LASSEN, MSW, LCSW, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICIAN
Authorized Official - Prefix:
Authorized Official - First Name:BAMBI
Authorized Official - Middle Name:R
Authorized Official - Last Name:LASSEN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:208-290-5592
Mailing Address - Street 1:PO BOX 10
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:ID
Mailing Address - Zip Code:83825-0010
Mailing Address - Country:US
Mailing Address - Phone:208-290-5592
Mailing Address - Fax:208-263-4478
Practice Address - Street 1:102 S EUCLID AVE STE 111
Practice Address - Street 2:
Practice Address - City:SANDPOINT
Practice Address - State:ID
Practice Address - Zip Code:83864-4916
Practice Address - Country:US
Practice Address - Phone:208-263-4477
Practice Address - Fax:208-263-4478
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-08
Last Update Date:2017-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID29490104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1063581429Medicaid