Healthcare Provider Details

I. General information

NPI: 1679670319
Provider Name (Legal Business Name): GINA WOLFE SEYBOLD LICENSED CLINICAL PR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: GINA E WOLFE LICENSED CLINICAL PR

II. Dates (important events)

Enumeration Date: 09/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1408 W HAYS ST
BOISE ID
83702
US

IV. Provider business mailing address

1408 W HAYS ST
BOISE ID
83702
US

V. Phone/Fax

Practice location:
  • Phone: 208-387-0778
  • Fax: 208-336-7125
Mailing address:
  • Phone: 208-387-0778
  • Fax: 208-336-7125

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLCPC122
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: