Provider Demographics
NPI:1053146464
Name:DAVYDOV, YURI (LPC)
Entity type:Individual
Prefix:
First Name:YURI
Middle Name:
Last Name:DAVYDOV
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 1:344 RIO VISTA BLVD
Mailing Address - Street 2:
Mailing Address - City:MCCALL
Mailing Address - State:ID
Mailing Address - Zip Code:83638-4302
Mailing Address - Country:US
Mailing Address - Phone:208-830-8520
Mailing Address - Fax:
Practice Address - Street 1:125 S SAMSON TRL
Practice Address - Street 2:
Practice Address - City:MCCALL
Practice Address - State:ID
Practice Address - Zip Code:83638-5187
Practice Address - Country:US
Practice Address - Phone:208-830-8520
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-05
Last Update Date:2024-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor