Healthcare Provider Details

I. General information

NPI: 1104406065
Provider Name (Legal Business Name): ELISSA PFAU LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2021
Last Update Date: 04/13/2021
Certification Date: 04/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8601 W EMERALD ST STE 130
BOISE ID
83704-8209
US

IV. Provider business mailing address

1553 E TUTTLE ST
MERIDIAN ID
83646-4861
US

V. Phone/Fax

Practice location:
  • Phone: 208-600-2184
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC-7286
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: