Healthcare Provider Details

I. General information

NPI: 1457084667
Provider Name (Legal Business Name): IMPACT COUNSELING AND TREATMENT SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2022
Last Update Date: 08/21/2024
Certification Date: 08/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6003 W OVERLAND RD STE 101
BOISE ID
83709-3075
US

IV. Provider business mailing address

961 E ODYSSEY ST
KUNA ID
83634-5618
US

V. Phone/Fax

Practice location:
  • Phone: 208-917-2543
  • Fax: 208-917-8598
Mailing address:
  • Phone: 208-576-9239
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MERRIDITH MANNING
Title or Position: MEMBER, OWNER
Credential: LMFT
Phone: 208-917-2543