Healthcare Provider Details

I. General information

NPI: 1013745546
Provider Name (Legal Business Name): COMMONPLACE WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2024
Last Update Date: 05/18/2025
Certification Date: 05/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 W BANNOCK ST
BOISE ID
83702-5916
US

IV. Provider business mailing address

205 S BRUCE LN
BOISE ID
83712-7804
US

V. Phone/Fax

Practice location:
  • Phone: 208-906-5878
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: ISSA NTAKARUTIMANA
Title or Position: OWNER / CLINICIAN
Credential: LCSW
Phone: 208-906-5878