Provider Demographics
NPI:1255729745
Name:BIRDZELL, CAROL JEAN (LPC)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:JEAN
Last Name:BIRDZELL
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:CAROL
Other - Middle Name:JEAN
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CPM,LM
Mailing Address - Street 1:1065 E WINDING CREEK DR STE 250
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-7246
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1065 E WINDING CREEK DR STE 250
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-7246
Practice Address - Country:US
Practice Address - Phone:208-244-8105
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-06
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-9987101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional