Provider Demographics
NPI:1891316972
Name:LOTT, MARY (LCPC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:LOTT
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:595 W WARREN ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-3959
Mailing Address - Country:US
Mailing Address - Phone:208-353-2654
Mailing Address - Fax:
Practice Address - Street 1:6300 W DENTON ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-9326
Practice Address - Country:US
Practice Address - Phone:208-577-4870
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-30
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID101YP2500X
IDLCPC-7592101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional