Provider Demographics
NPI:1619323649
Name:BYNUM, JOSHUA (MS)
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:
Last Name:BYNUM
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:544 N EAGLE RD
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-5004
Mailing Address - Country:US
Mailing Address - Phone:208-477-8351
Mailing Address - Fax:
Practice Address - Street 1:651 N EAGLE RD
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-5007
Practice Address - Country:US
Practice Address - Phone:208-477-8351
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-09
Last Update Date:2018-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-6173101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional