Provider Demographics
NPI:1386660678
Name:BOOK, PHARES L (PSYD,LPC)
Entity Type:Individual
Prefix:
First Name:PHARES
Middle Name:L
Last Name:BOOK
Suffix:
Gender:M
Credentials:PSYD,LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:815 FILLMORE ST
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83605-4126
Mailing Address - Country:US
Mailing Address - Phone:208-459-6962
Mailing Address - Fax:208-459-4476
Practice Address - Street 1:815 FILLMORE ST
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-4126
Practice Address - Country:US
Practice Address - Phone:208-459-6962
Practice Address - Fax:208-459-4476
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2012-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID202193103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807284400Medicaid
ID1684828Medicare ID - Type Unspecified