Healthcare Provider Details

I. General information

NPI: 1255052965
Provider Name (Legal Business Name): CORNERSTONE FAMILY THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2022
Last Update Date: 04/24/2024
Certification Date: 04/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2995 N COLE RD STE 225
BOISE ID
83704-5966
US

IV. Provider business mailing address

PO BOX 190213
BOISE ID
83719-0213
US

V. Phone/Fax

Practice location:
  • Phone: 208-614-0588
  • Fax: 208-203-7432
Mailing address:
  • Phone: 208-614-0588
  • Fax: 208-203-7432

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 Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: REBECCA LINDSEY GONZALES
Title or Position: OWNER, CLINICIAN
Credential: LMFT, LCPC
Phone: 208-571-0711