Provider Demographics
NPI:1174980205
Name:LORA-SALAS, YEZENIA
Entity type:Individual
Prefix:
First Name:YEZENIA
Middle Name:
Last Name:LORA-SALAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 3 BOX 288
Mailing Address - Street 2:
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221-9792
Mailing Address - Country:US
Mailing Address - Phone:208-339-5686
Mailing Address - Fax:
Practice Address - Street 1:RR 3 BOX 288
Practice Address - Street 2:
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221-9792
Practice Address - Country:US
Practice Address - Phone:208-339-5686
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-20
Last Update Date:2016-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW35292104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker