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NPI Code Detail

MEDICARE: EMALISSA BROOKE ANNE BALENTINE

MEDICARE: EMALISSA BROOKE ANNE BALENTINE
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1385HR2055XChild Mental Illness Respite Care

General Provider Information

NPI Number : 1063364743
Entity Type Code : Individual
Provider Name (Legal Business Name) : EMALISSA BROOKE ANNE BALENTINE
Provider Business Mailing Address
First Line : 531 BRYDEN AVE
Second Line :
City : LEWISTON
State : ID
Zip : 83501-4438
Country : US
Telephone Number : 208-798-1646
Fax Number : 208-798-5568
Provider Business Practice Location Address
First Line : 531 BRYDEN AVE
Second Line :
City : LEWISTON
State : ID
Zip : 83501-4438
Country : US
Telephone Number : 208-798-1646
Fax Number : 208-798-5568
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 02/13/2026
Last Update Date : 02/13/2026

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Directions to “ EMALISSA BROOKE ANNE BALENTINE ” Practice Location

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