Provider Demographics
NPI:1619015351
Name:NEVALA, JAMES RABE (LPC)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:RABE
Last Name:NEVALA
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2604 BIRDIE THOMPSON DR
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-2741
Mailing Address - Country:US
Mailing Address - Phone:208-269-0679
Mailing Address - Fax:
Practice Address - Street 1:4460 CENTRAL WAY
Practice Address - Street 2:SUITE 2
Practice Address - City:CHUBBUCK
Practice Address - State:ID
Practice Address - Zip Code:83202-5095
Practice Address - Country:US
Practice Address - Phone:208-237-1711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2009-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-4378101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807197600Medicaid