Healthcare Provider Details

I. General information

NPI: 1043114796
Provider Name (Legal Business Name): ADDISON SQUIBB
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2026
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

740 E WARM SPRINGS AVE
BOISE ID
83712-6420
US

IV. Provider business mailing address

740 E WARM SPRINGS AVE
BOISE ID
83712-6420
US

V. Phone/Fax

Practice location:
  • Phone: 208-343-7797
  • Fax:
Mailing address:
  • Phone: 208-343-7797
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: