Provider Demographics
NPI:1043468903
Name:RAYMOND, BRIAN (LCSW)
Entity type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:
Last Name:RAYMOND
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 1:10022 W DYLAN CT
Mailing Address - Street 2:
Mailing Address - City:STAR
Mailing Address - State:ID
Mailing Address - Zip Code:83669-5643
Mailing Address - Country:US
Mailing Address - Phone:208-571-2723
Mailing Address - Fax:208-348-5573
Practice Address - Street 1:10022 W DYLAN CT
Practice Address - Street 2:
Practice Address - City:STAR
Practice Address - State:ID
Practice Address - Zip Code:83669-5643
Practice Address - Country:US
Practice Address - Phone:208-571-2723
Practice Address - Fax:208-348-5573
Is Sole Proprietor?:No
Enumeration Date:2008-09-04
Last Update Date:2016-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW 321321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID12403159OtherCAQH
ID002920900Medicaid
ID134009Medicare PIN
ID12403159OtherCAQH