Provider Demographics
NPI:1144618521
Name:PETERS, MARCY LYNN (LCSW)
Entity type:Individual
Prefix:
First Name:MARCY
Middle Name:LYNN
Last Name:PETERS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:698 N MINERAL WELLS AVE
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-7610
Mailing Address - Country:US
Mailing Address - Phone:661-674-7104
Mailing Address - Fax:
Practice Address - Street 1:3350 W AMERICANA TER
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-2521
Practice Address - Country:US
Practice Address - Phone:661-674-7104
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-07
Last Update Date:2025-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCFH-10581310400000X
ID88611221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility