Provider Demographics
NPI:1912248519
Name:IMESON, CARY (LCSW)
Entity Type:Individual
Prefix:
First Name:CARY
Middle Name:
Last Name:IMESON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:CAROLENA
Other - Middle Name:
Other - Last Name:IMESON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:2057 E HIDDEN COVE LN
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-7640
Mailing Address - Country:US
Mailing Address - Phone:208-724-8486
Mailing Address - Fax:
Practice Address - Street 1:2057 E HIDDEN COVE LN
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-7640
Practice Address - Country:US
Practice Address - Phone:208-724-8486
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-06
Last Update Date:2024-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW33065104100000X
IDLCSW-376081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker