Healthcare Provider Details

I. General information

NPI: 1467115428
Provider Name (Legal Business Name): SCOTT STANTLIFF LCPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2021
Last Update Date: 06/19/2026
Certification Date: 06/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1109 W MYRTLE ST STE 200
BOISE ID
83702-6975
US

IV. Provider business mailing address

190 E BANNOCK ST
BOISE ID
83712-6241
US

V. Phone/Fax

Practice location:
  • Phone: 208-706-6375
  • Fax: 208-706-6395
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLCPC-10257
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: