Provider Demographics
NPI:1396023065
Name:SMITH, RHEANON RENE' (LCPC)
Entity Type:Individual
Prefix:
First Name:RHEANON
Middle Name:RENE'
Last Name:SMITH
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6933 W EMERALD ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-8616
Mailing Address - Country:US
Mailing Address - Phone:208-321-0634
Mailing Address - Fax:
Practice Address - Street 1:6933 W EMERALD ST STE 100
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8616
Practice Address - Country:US
Practice Address - Phone:208-321-0634
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-29
Last Update Date:2019-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC5443101Y00000X
IDLPC 4616101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1265565477Medicaid
ID1396023065Medicaid