Healthcare Provider Details

I. General information

NPI: 1669825709
Provider Name (Legal Business Name): HEIDI SENETHAVILAY PHD, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2016
Last Update Date: 12/21/2023
Certification Date: 12/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1883 WILDWOOD ST STE G
BOISE ID
83713-5146
US

IV. Provider business mailing address

4954 N WILD GOOSE WAY
MERIDIAN ID
83646-5988
US

V. Phone/Fax

Practice location:
  • Phone: 208-484-0920
  • Fax:
Mailing address:
  • Phone: 702-467-0876
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberSE-202979
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberLPC-7920
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: