Healthcare Provider Details

I. General information

NPI: 1336477207
Provider Name (Legal Business Name): RD BOARDMAN LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/03/2009
Last Update Date: 10/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HEALTH SERVICES 1529 BELMONT ST
BOISE ID
83725-0001
US

IV. Provider business mailing address

HEALTH SERVICES 1529 BELMONT ST
BOISE ID
83725-0001
US

V. Phone/Fax

Practice location:
  • Phone: 208-426-1459
  • Fax: 208-426-3005
Mailing address:
  • Phone: 208-426-1459
  • Fax: 208-426-3005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberPSY - 202708
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: