Provider Demographics
NPI:1700189156
Name:WHIPPLE, CHARLES GREGORY (LCSW)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:GREGORY
Last Name:WHIPPLE
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 1:6633 W WRIGHT ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-4354
Mailing Address - Country:US
Mailing Address - Phone:208-375-7777
Mailing Address - Fax:208-375-7598
Practice Address - Street 1:6633 W WRIGHT ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-4354
Practice Address - Country:US
Practice Address - Phone:208-375-7777
Practice Address - Fax:208-375-7598
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-07
Last Update Date:2010-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW7731041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDLCSW773OtherIDAHO LICENSE