Provider Demographics
NPI:1376804179
Name:GRANT, RAELYNN FRITZ (LPC)
Entity Type:Individual
Prefix:MRS
First Name:RAELYNN
Middle Name:FRITZ
Last Name:GRANT
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 1:1415 S COLORADO AVE
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-3741
Mailing Address - Country:US
Mailing Address - Phone:208-761-0980
Mailing Address - Fax:
Practice Address - Street 1:410 S ORCHARD ST STE 132
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-1288
Practice Address - Country:US
Practice Address - Phone:208-761-0980
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-07
Last Update Date:2012-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC 4853101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor