Provider Demographics
NPI:1285671677
Name:HUOT, EVELYN (LCSW)
Entity Type:Individual
Prefix:
First Name:EVELYN
Middle Name:
Last Name:HUOT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:EVELYN
Other - Middle Name:
Other - Last Name:MALLEA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:1899 VIRGINIA AVE
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-6208
Mailing Address - Country:US
Mailing Address - Phone:208-731-6302
Mailing Address - Fax:208-522-8725
Practice Address - Street 1:1740 E 17TH ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6375
Practice Address - Country:US
Practice Address - Phone:208-522-8725
Practice Address - Fax:208-522-8725
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-02
Last Update Date:2008-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW 7791041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1690566Medicare PIN