Healthcare Provider Details

I. General information

NPI: 1376489427
Provider Name (Legal Business Name): MICHAEL CHIPPOLLA LCSW ACADC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2026
Last Update Date: 04/28/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4836 W TARGEE ST
BOISE ID
83705-3655
US

IV. Provider business mailing address

4836 W TARGEE ST
BOISE ID
83705-3655
US

V. Phone/Fax

Practice location:
  • Phone: 208-713-5250
  • Fax:
Mailing address:
  • Phone: 208-713-5250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MICHAEL CHIPPOLLA
Title or Position: OWNER- CLINICAL DIRECTOR
Credential: LCSW 35126
Phone: 208-713-5250