Provider Demographics
NPI:1831821768
Name:PREVOST, RAYMOND JOSEPH (LMSW)
Entity type:Individual
Prefix:MR
First Name:RAYMOND
Middle Name:JOSEPH
Last Name:PREVOST
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5452 N STUART ST
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83815-9492
Mailing Address - Country:US
Mailing Address - Phone:208-661-3054
Mailing Address - Fax:
Practice Address - Street 1:427 12TH ST
Practice Address - Street 2:
Practice Address - City:PLUMMER
Practice Address - State:ID
Practice Address - Zip Code:83851-4000
Practice Address - Country:US
Practice Address - Phone:208-686-1931
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-29
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-42383104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker