Healthcare Provider Details

I. General information

NPI: 1184544884
Provider Name (Legal Business Name): ELENA MARIA MABANTA LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2026
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3852 N EAGLE RD
BOISE ID
83713-0750
US

IV. Provider business mailing address

3997 S CONSTITUTION WAY
BOISE ID
83706-5817
US

V. Phone/Fax

Practice location:
  • Phone: 208-378-0014
  • Fax:
Mailing address:
  • Phone: 503-545-0481
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2381112
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: