Provider Demographics
NPI:1104481530
Name:LABRA, ITZEL
Entity type:Individual
Prefix:
First Name:ITZEL
Middle Name:
Last Name:LABRA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1970 E 17TH ST STE 208
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-8048
Mailing Address - Country:US
Mailing Address - Phone:208-932-0668
Mailing Address - Fax:208-932-0809
Practice Address - Street 1:1970 E 17TH ST STE 208
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-8048
Practice Address - Country:US
Practice Address - Phone:208-932-0668
Practice Address - Fax:208-932-0809
Is Sole Proprietor?:No
Enumeration Date:2019-05-01
Last Update Date:2019-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW38542104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker