Healthcare Provider Details

I. General information

NPI: 1619760501
Provider Name (Legal Business Name): DYNOVION COGNITIVE WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2025
Last Update Date: 05/23/2025
Certification Date: 05/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12550 W EXPLORER DR
BOISE ID
83713-1826
US

IV. Provider business mailing address

14233 SILVER RIDGE RD
CALDWELL ID
83607-5448
US

V. Phone/Fax

Practice location:
  • Phone: 986-230-2245
  • Fax:
Mailing address:
  • Phone: 208-964-7189
  • Fax:

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 Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: TIMOTHY J HOEKSTRA
Title or Position: CEO
Credential:
Phone: 208-964-7189