Provider Demographics
NPI:1861651812
Name:REX, MICHAEL (LCSW)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:REX
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 1:3422 S 15TH E
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-8262
Mailing Address - Country:US
Mailing Address - Phone:208-523-5055
Mailing Address - Fax:208-524-1701
Practice Address - Street 1:3422 S 15TH E
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-8262
Practice Address - Country:US
Practice Address - Phone:208-523-5055
Practice Address - Fax:208-524-1701
Is Sole Proprietor?:No
Enumeration Date:2008-06-05
Last Update Date:2009-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW27564104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805348500Medicaid
ID805348500Medicaid