Healthcare Provider Details

I. General information

NPI: 1043021702
Provider Name (Legal Business Name): KIRI VAWDREY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/14/2025
Last Update Date: 01/14/2025
Certification Date: 01/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8620 W EMERALD ST STE 150
BOISE ID
83704-4839
US

IV. Provider business mailing address

8620 W EMERALD ST STE 150
BOISE ID
83704-4839
US

V. Phone/Fax

Practice location:
  • Phone: 208-617-3265
  • Fax: 208-617-3270
Mailing address:
  • Phone: 208-617-3265
  • Fax: 208-617-3270

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1561272
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: