Provider Demographics
NPI:1902936362
Name:BINGHAM, MALYA (LPC)
Entity Type:Individual
Prefix:
First Name:MALYA
Middle Name:
Last Name:BINGHAM
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 W MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:GLENNS FERRY
Mailing Address - State:ID
Mailing Address - Zip Code:83623-2364
Mailing Address - Country:US
Mailing Address - Phone:208-366-2185
Mailing Address - Fax:
Practice Address - Street 1:486 WEST 1ST AVE
Practice Address - Street 2:
Practice Address - City:GLENNS FERRY
Practice Address - State:ID
Practice Address - Zip Code:83623-0266
Practice Address - Country:US
Practice Address - Phone:208-366-7416
Practice Address - Fax:208-366-2595
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-3498101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDLPC-3498OtherIDAHO LICENSE #
IDX6899OtherBLUE CROSS OF IDAHO #
ID000010156752OtherBLUESHIELD OF IDAHO #