Healthcare Provider Details

I. General information

NPI: 1043871668
Provider Name (Legal Business Name): NATHAN FAUNTLEROY LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2019
Last Update Date: 06/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1529 BELMONT ST
BOISE ID
83706
US

IV. Provider business mailing address

1247 S DIVISION AVE
BOISE ID
83706-3652
US

V. Phone/Fax

Practice location:
  • Phone: 208-426-1459
  • Fax:
Mailing address:
  • Phone: 317-755-6008
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number38789
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: