Healthcare Provider Details

I. General information

NPI: 1538840699
Provider Name (Legal Business Name): KIMBERLY NEEDHAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2023
Last Update Date: 07/31/2023
Certification Date: 07/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9490 W FAIRVIEW AVE
BOISE ID
83704-8101
US

IV. Provider business mailing address

9368 W MARIGOLD ST
BOISE ID
83714-1143
US

V. Phone/Fax

Practice location:
  • Phone: 208-486-0556
  • Fax:
Mailing address:
  • Phone: 208-515-6048
  • 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:
Title or Position:
Credential:
Phone: