Provider Demographics
NPI:1952069213
Name:GLOVER, TRACI LYNN (LPC, LSW)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:LYNN
Last Name:GLOVER
Suffix:
Gender:F
Credentials:LPC, LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 421
Mailing Address - Street 2:
Mailing Address - City:KUNA
Mailing Address - State:ID
Mailing Address - Zip Code:83634-0421
Mailing Address - Country:US
Mailing Address - Phone:888-311-1883
Mailing Address - Fax:
Practice Address - Street 1:750 E WARM SPRINGS AVE
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-6475
Practice Address - Country:US
Practice Address - Phone:888-311-1883
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-03
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLPCC.0018210101Y00000X
IDLSW-1689104100000X
IDLPC-4138101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No104100000XBehavioral Health & Social Service ProvidersSocial Worker