Provider Demographics
NPI:1780875443
Name:THATCHER, MYRNA SUE (LMFT)
Entity type:Individual
Prefix:
First Name:MYRNA
Middle Name:SUE
Last Name:THATCHER
Suffix:
Gender:F
Credentials:LMFT
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 506
Mailing Address - Street 2:
Mailing Address - City:COTTONWOOD
Mailing Address - State:ID
Mailing Address - Zip Code:83522-0506
Mailing Address - Country:US
Mailing Address - Phone:208-962-7384
Mailing Address - Fax:
Practice Address - Street 1:976 HAAS RANCH RD
Practice Address - Street 2:
Practice Address - City:CRAIGMONT
Practice Address - State:ID
Practice Address - Zip Code:83523
Practice Address - Country:US
Practice Address - Phone:208-962-7384
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-07
Last Update Date:2007-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMFT-2654106H00000X
KSLCMFT-053106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010158872OtherREGENCE BLUE SHIELD