Healthcare Provider Details

I. General information

NPI: 1154404341
Provider Name (Legal Business Name): GAIL M BACCHESCHI MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1408 WEST HAYS STREET
BOISE ID
83702
US

IV. Provider business mailing address

1408 WEST HAYS STREET
BOISE ID
83702
US

V. Phone/Fax

Practice location:
  • Phone: 208-343-1403
  • Fax: 208-336-7125
Mailing address:
  • Phone: 208-343-1403
  • Fax: 208-336-7125

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLCSW522
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number1257103501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: