Provider Demographics
NPI:1154563948
Name:WOLERY, BECKY JEAN (LCSW)
Entity type:Individual
Prefix:MRS
First Name:BECKY
Middle Name:JEAN
Last Name:WOLERY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3340 E. GOLDSTONE DR.
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642
Mailing Address - Country:US
Mailing Address - Phone:208-452-8000
Mailing Address - Fax:208-452-8055
Practice Address - Street 1:910 NW 16TH ST STE 101
Practice Address - Street 2:
Practice Address - City:FRUITLAND
Practice Address - State:ID
Practice Address - Zip Code:83619
Practice Address - Country:US
Practice Address - Phone:208-452-8000
Practice Address - Fax:208-452-8055
Is Sole Proprietor?:No
Enumeration Date:2009-03-25
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-307771041C0700X
IDLMSW-28988104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical