Provider Demographics
NPI:1265865554
Name:PRIESTLEY, DAVID RONALD (LCSW)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:RONALD
Last Name:PRIESTLEY
Suffix:
Gender:M
Credentials:LCSW
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 54
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:ID
Mailing Address - Zip Code:83237-0054
Mailing Address - Country:US
Mailing Address - Phone:208-852-2370
Mailing Address - Fax:208-852-5570
Practice Address - Street 1:75 S 1ST W
Practice Address - Street 2:
Practice Address - City:PRESTON
Practice Address - State:ID
Practice Address - Zip Code:83263-1204
Practice Address - Country:US
Practice Address - Phone:208-852-2370
Practice Address - Fax:208-852-5570
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-09
Last Update Date:2013-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-30965101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1073660320Medicaid