Provider Demographics
NPI:1902043524
Name:BUBAR, MARLENE MYRA (MARLENE BUBAR)
Entity Type:Individual
Prefix:MS
First Name:MARLENE
Middle Name:MYRA
Last Name:BUBAR
Suffix:
Gender:F
Credentials:MARLENE BUBAR
Other - Prefix:MISS
Other - First Name:MARLENE
Other - Middle Name:MYRA
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MARLENE BUBAR, LCSW
Mailing Address - Street 1:722 NORVIN AVE
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-3047
Mailing Address - Country:US
Mailing Address - Phone:208-524-4937
Mailing Address - Fax:
Practice Address - Street 1:722 NORVIN AVE
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-3047
Practice Address - Country:US
Practice Address - Phone:208-524-4937
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-20
Last Update Date:2009-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-5571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical