Provider Demographics
NPI:1396411724
Name:LONGACRE, ARLITTA RAE
Entity type:Individual
Prefix:
First Name:ARLITTA
Middle Name:RAE
Last Name:LONGACRE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1350 JOHNSON PL
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-3063
Mailing Address - Country:US
Mailing Address - Phone:208-521-6124
Mailing Address - Fax:
Practice Address - Street 1:1350 JOHNSON PL
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-3063
Practice Address - Country:US
Practice Address - Phone:208-521-6124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-17
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician