Healthcare Provider Details

I. General information

NPI: 1396398327
Provider Name (Legal Business Name): ERICKA OBAITEK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2019
Last Update Date: 07/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1529 BELMONT ST
BOISE ID
83706-8370
US

IV. Provider business mailing address

1829 W BOISE AVE APT D
BOISE ID
83706-3499
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLMSW-38750
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: