Provider Demographics
NPI:1184969578
Name:MCGINNIS, MARY IRENE (LMSW)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:IRENE
Last Name:MCGINNIS
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 E 6TH ST
Mailing Address - Street 2:
Mailing Address - City:RUPERT
Mailing Address - State:ID
Mailing Address - Zip Code:83350-1723
Mailing Address - Country:US
Mailing Address - Phone:208-670-0027
Mailing Address - Fax:
Practice Address - Street 1:2311 PARK AVE
Practice Address - Street 2:UNIT 3 SUITE 12
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318-2170
Practice Address - Country:US
Practice Address - Phone:208-678-3555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-11
Last Update Date:2012-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW24487104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker