Provider Demographics
NPI:1316110273
Name:HAGLER, LYNETTA RUTH (LCSW)
Entity type:Individual
Prefix:MS
First Name:LYNETTA
Middle Name:RUTH
Last Name:HAGLER
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 1:1277 E 17TH ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-6126
Mailing Address - Country:US
Mailing Address - Phone:208-523-0787
Mailing Address - Fax:208-523-3175
Practice Address - Street 1:1277 E 17TH ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6126
Practice Address - Country:US
Practice Address - Phone:208-523-0787
Practice Address - Fax:208-523-3175
Is Sole Proprietor?:No
Enumeration Date:2008-04-10
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW1367101YM0800X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical