Provider Demographics
NPI:1235130162
Name:BOURCY, LYLE SPENCER (LCPC)
Entity Type:Individual
Prefix:MR
First Name:LYLE
Middle Name:SPENCER
Last Name:BOURCY
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1303 NW 16TH ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:FRUITLAND
Mailing Address - State:ID
Mailing Address - Zip Code:83619-2263
Mailing Address - Country:US
Mailing Address - Phone:208-250-0374
Mailing Address - Fax:208-452-2164
Practice Address - Street 1:1303 NW 16TH ST
Practice Address - Street 2:SUITE C
Practice Address - City:FRUITLAND
Practice Address - State:ID
Practice Address - Zip Code:83619-2263
Practice Address - Country:US
Practice Address - Phone:208-250-0374
Practice Address - Fax:208-452-2164
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC-2757101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDQ3543OtherBLUE CROSS OF IDAHO PROVI
ID0000101364OtherBLUE SHIELD OF IDAHO