Healthcare Provider Details

I. General information

NPI: 1306230958
Provider Name (Legal Business Name): NORTHEND WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2015
Last Update Date: 06/28/2023
Certification Date: 06/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1310 W HAYS ST
BOISE ID
83702-5025
US

IV. Provider business mailing address

1310 W HAYS ST
BOISE ID
83702-5025
US

V. Phone/Fax

Practice location:
  • Phone: 208-949-6765
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number202232
License Number StateID

VIII. Authorized Official

Name: DAVID CUMMINS
Title or Position: OWNER
Credential:
Phone: 208-949-6765