Provider Demographics
NPI:1811105042
Name:LUIS, MANDY J (LCSW)
Entity type:Individual
Prefix:
First Name:MANDY
Middle Name:J
Last Name:LUIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MANDY
Other - Middle Name:
Other - Last Name:JONES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:550 2ND ST
Mailing Address - Street 2:P.O.BOX 1876
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-3900
Mailing Address - Country:US
Mailing Address - Phone:208-529-2211
Mailing Address - Fax:208-529-4647
Practice Address - Street 1:550 2ND ST
Practice Address - Street 2:SUITE 292
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-3900
Practice Address - Country:US
Practice Address - Phone:208-529-2211
Practice Address - Fax:208-529-4647
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-20
Last Update Date:2025-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLSW24674104100000X
IDLCSW-400861041C0700X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker