Healthcare Provider Details

I. General information

NPI: 1679383137
Provider Name (Legal Business Name): SKYLER WIXOM LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/08/2025
Last Update Date: 01/08/2025
Certification Date: 01/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1910 UNIVERSITY DR
BOISE ID
83725-0002
US

IV. Provider business mailing address

1910 UNIVERSITY DR
BOISE ID
83725-0002
US

V. Phone/Fax

Practice location:
  • Phone: 208-426-1459
  • Fax: 208-426-3005
Mailing address:
  • Phone: 208-426-1459
  • Fax: 208-426-3005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number5371946
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: