Provider Demographics
NPI:1457020794
Name:MASSOTH, LOUIS ALEXANDER (LCSW)
Entity Type:Individual
Prefix:
First Name:LOUIS
Middle Name:ALEXANDER
Last Name:MASSOTH
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 1:5700 E FRANKLIN RD STE 220I
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83687-5065
Mailing Address - Country:US
Mailing Address - Phone:208-889-8060
Mailing Address - Fax:208-899-8757
Practice Address - Street 1:5700 E FRANKLIN RD STE 220I
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83687-5065
Practice Address - Country:US
Practice Address - Phone:208-889-8060
Practice Address - Fax:208-899-8757
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-09
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID1160101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional