Provider Demographics
NPI:1194845974
Name:LAWRENCE, WILLIAM MICHAEL (BS)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:MICHAEL
Last Name:LAWRENCE
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 513
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:ID
Mailing Address - Zip Code:83647-0513
Mailing Address - Country:US
Mailing Address - Phone:208-587-2900
Mailing Address - Fax:208-587-2992
Practice Address - Street 1:235 N 3RD E
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:ID
Practice Address - Zip Code:83647-2734
Practice Address - Country:US
Practice Address - Phone:208-587-2900
Practice Address - Fax:208-587-2992
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8060918Medicaid