Provider Demographics
NPI:1265822282
Name:FLEENOR, EVELYN (MC)
Entity Type:Individual
Prefix:
First Name:EVELYN
Middle Name:
Last Name:FLEENOR
Suffix:
Gender:F
Credentials:MC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7412 W PREECE DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-9039
Mailing Address - Country:US
Mailing Address - Phone:208-830-9914
Mailing Address - Fax:
Practice Address - Street 1:7412 W PREECE DR
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-9039
Practice Address - Country:US
Practice Address - Phone:208-830-9914
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-29
Last Update Date:2015-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC4327101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor