Provider Demographics
NPI:1710269170
Name:ROBERTS, DAVID W (LCPC)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:W
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:MONTPELIER
Mailing Address - State:ID
Mailing Address - Zip Code:83254-1401
Mailing Address - Country:US
Mailing Address - Phone:208-220-4197
Mailing Address - Fax:
Practice Address - Street 1:335 N MAIN ST
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83204
Practice Address - Country:US
Practice Address - Phone:208-478-8340
Practice Address - Fax:208-478-8341
Is Sole Proprietor?:No
Enumeration Date:2011-09-12
Last Update Date:2022-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC-9221101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional