Provider Demographics
NPI:1801258694
Name:WAITE, MICHAEL (LCSW)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:WAITE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2074 E 990 S
Mailing Address - Street 2:
Mailing Address - City:HAZELTON
Mailing Address - State:ID
Mailing Address - Zip Code:83335-5040
Mailing Address - Country:US
Mailing Address - Phone:208-293-4744
Mailing Address - Fax:
Practice Address - Street 1:823 HARRISON ST
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-3925
Practice Address - Country:US
Practice Address - Phone:208-736-2177
Practice Address - Fax:208-736-2113
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-22
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-9461041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical