Provider Demographics
NPI:1417978347
Name:NUSBAUM, GEOFFREY D (PHD)
Entity type:Individual
Prefix:
First Name:GEOFFREY
Middle Name:D
Last Name:NUSBAUM
Suffix:
Gender:M
Credentials:PHD
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 4449
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83205-4449
Mailing Address - Country:US
Mailing Address - Phone:208-234-2660
Mailing Address - Fax:208-234-2661
Practice Address - Street 1:333 N 18TH AVE STE A
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-3358
Practice Address - Country:US
Practice Address - Phone:208-234-2660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMFT-38101Y00000X
PAMF000283101Y00000X
NJ101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor