Healthcare Provider Details

I. General information

NPI: 1821681982
Provider Name (Legal Business Name): ISSA NTAKARUTIMANA LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: NTAKAUTIMANA ISSA

II. Dates (important events)

Enumeration Date: 02/18/2021
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 W BANNOCK ST
BOISE ID
83702-5916
US

IV. Provider business mailing address

205 S BRUCE LN
BOISE ID
83712-7804
US

V. Phone/Fax

Practice location:
  • Phone: 208-329-8658
  • Fax: 208-473-7270
Mailing address:
  • Phone: 208-906-5878
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number8861545
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number8861545
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: