Provider Demographics
NPI:1235376062
Name:BOZORG-OMID, RENEE LYNN (LPC)
Entity Type:Individual
Prefix:DR
First Name:RENEE
Middle Name:LYNN
Last Name:BOZORG-OMID
Suffix:
Gender:F
Credentials:LPC
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 4455
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83205-4455
Mailing Address - Country:US
Mailing Address - Phone:912-660-2674
Mailing Address - Fax:
Practice Address - Street 1:500 S 11TH AVE STE 302
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4879
Practice Address - Country:US
Practice Address - Phone:208-233-0150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-15
Last Update Date:2009-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC 3249101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional