Provider Demographics
NPI:1194187898
Name:FIELDSTAD, ERIC J II (LCSW)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:J
Last Name:FIELDSTAD
Suffix:II
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:PO BOX 45581
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83711-5581
Mailing Address - Country:US
Mailing Address - Phone:208-880-3837
Mailing Address - Fax:
Practice Address - Street 1:5185 W OVERLAND RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-2635
Practice Address - Country:US
Practice Address - Phone:208-918-0697
Practice Address - Fax:208-342-7584
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-22
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-34845104100000X, 1041S0200X
IDLCSW-381921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool