Healthcare Provider Details

I. General information

NPI: 1801148077
Provider Name (Legal Business Name): RACHEL ROOT PHD LP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2012
Last Update Date: 07/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

671 E RIVERPARK LN STE 220
BOISE ID
83706
US

IV. Provider business mailing address

671 E RIVERPARK LN STE 220
BOISE ID
83706-6559
US

V. Phone/Fax

Practice location:
  • Phone: 208-344-2071
  • Fax: 208-344-2075
Mailing address:
  • Phone: 208-344-2071
  • Fax: 208-344-2075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberPSY-202658
License Number StateID

VIII. Authorized Official

Name: RACHEL ANNE ROOT
Title or Position: PRESIDENT
Credential: PHD
Phone: 208-344-2071