Provider Demographics
NPI:1306974365
Name:LUSBY, LAURISA ROGERS (LCSW)
Entity type:Individual
Prefix:
First Name:LAURISA
Middle Name:ROGERS
Last Name:LUSBY
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 1:2584 E BERGESON ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-6014
Mailing Address - Country:US
Mailing Address - Phone:208-921-3501
Mailing Address - Fax:208-343-1371
Practice Address - Street 1:413 ALLUMBAUGH ST
Practice Address - Street 2:STE 102
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-9212
Practice Address - Country:US
Practice Address - Phone:208-287-0993
Practice Address - Fax:208-287-0996
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID263131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDL5916OtherBLUE CROSS