Healthcare Provider Details

I. General information

NPI: 1710178876
Provider Name (Legal Business Name): SAMUEL PHILLIP LUQUE LPC,
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2007
Last Update Date: 05/16/2023
Certification Date: 05/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1055 N CURTIS RD
BOISE ID
83706
US

IV. Provider business mailing address

PO BOX 190930
BOISE ID
83719-0930
US

V. Phone/Fax

Practice location:
  • Phone: 208-367-2121
  • Fax:
Mailing address:
  • Phone: 208-367-5170
  • Fax: 208-367-6180

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC-3615
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: