Provider Demographics
NPI:1851720197
Name:MECHAM, VICTORIA L (LCSW)
Entity Type:Individual
Prefix:MS
First Name:VICTORIA
Middle Name:L
Last Name:MECHAM
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 S STOUT AVE
Mailing Address - Street 2:
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221-2943
Mailing Address - Country:US
Mailing Address - Phone:208-785-5810
Mailing Address - Fax:208-522-4364
Practice Address - Street 1:320 B ST STE 109
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-3547
Practice Address - Country:US
Practice Address - Phone:208-528-5434
Practice Address - Fax:208-522-4364
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-07
Last Update Date:2013-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-250421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical