Healthcare Provider Details

I. General information

NPI: 1124807631
Provider Name (Legal Business Name): LEANN W VATERLAUS LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2023
Last Update Date: 08/26/2024
Certification Date: 08/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6126 W STATE ST
BOISE ID
83703-2741
US

IV. Provider business mailing address

6126 W STATE ST
BOISE ID
83703-2741
US

V. Phone/Fax

Practice location:
  • Phone: 208-391-5941
  • Fax: 208-593-4807
Mailing address:
  • Phone: 208-391-5941
  • Fax: 208-593-4807

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLMSW-43080
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLMSW-43080
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: