Provider Demographics
NPI:1770724593
Name:HOLCOMB, DAVID NILES
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:NILES
Last Name:HOLCOMB
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:DAVID
Other - Middle Name:NILES
Other - Last Name:HOLCOMB
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:769 HIGHWAY 93 S
Mailing Address - Street 2:
Mailing Address - City:SALMON
Mailing Address - State:ID
Mailing Address - Zip Code:83467-5347
Mailing Address - Country:US
Mailing Address - Phone:208-940-1862
Mailing Address - Fax:
Practice Address - Street 1:769 HIGHWAY 93 S
Practice Address - Street 2:
Practice Address - City:SALMON
Practice Address - State:ID
Practice Address - Zip Code:83467-5347
Practice Address - Country:US
Practice Address - Phone:208-940-1862
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-09
Last Update Date:2013-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-266251041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LCSW-26625OtherINSURANCE