Provider Demographics
NPI:1558622001
Name:SCOVILLE-DORMAN, MICHELLE ANNETTE (LPC)
Entity Type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:ANNETTE
Last Name:SCOVILLE-DORMAN
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 1:4696 W OVERLAND RD
Mailing Address - Street 2:SUITE 252
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83705-2845
Mailing Address - Country:US
Mailing Address - Phone:208-841-3581
Mailing Address - Fax:208-906-8572
Practice Address - Street 1:4696 W OVERLAND RD
Practice Address - Street 2:SUITE 252
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-2845
Practice Address - Country:US
Practice Address - Phone:208-841-3581
Practice Address - Fax:208-906-8572
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-31
Last Update Date:2012-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-2923101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional