Provider Demographics
NPI:1730541608
Name:HOLBROOK, ASHTON W (LCSW)
Entity type:Individual
Prefix:MR
First Name:ASHTON
Middle Name:W
Last Name:HOLBROOK
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:167 N 710 W
Mailing Address - Street 2:
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221-5380
Mailing Address - Country:US
Mailing Address - Phone:208-417-9638
Mailing Address - Fax:
Practice Address - Street 1:167 N 710 W
Practice Address - Street 2:
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221-5380
Practice Address - Country:US
Practice Address - Phone:208-417-9638
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-22
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-440331041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical