Provider Demographics
NPI:1659669455
Name:HUCK, BRIAN WERNER (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:WERNER
Last Name:HUCK
Suffix:
Gender:M
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5557 W KINCREAG ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83714-1350
Mailing Address - Country:US
Mailing Address - Phone:208-284-4101
Mailing Address - Fax:
Practice Address - Street 1:450 W STATE ST STE 100
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-7055
Practice Address - Country:US
Practice Address - Phone:208-381-5970
Practice Address - Fax:208-381-5971
Is Sole Proprietor?:No
Enumeration Date:2011-07-13
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL61281041C0700X
IDLCSW-340271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
R175061Medicare PIN