Provider Demographics
NPI:1255764114
Name:OWENS, MARY LU (LMSW)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:LU
Last Name:OWENS
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:PO BOX 4824
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83711-4824
Mailing Address - Country:US
Mailing Address - Phone:208-697-6922
Mailing Address - Fax:
Practice Address - Street 1:1605 S KIMBALL AVE
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-4548
Practice Address - Country:US
Practice Address - Phone:208-454-2766
Practice Address - Fax:208-454-2771
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-14
Last Update Date:2013-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-24912101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health