Healthcare Provider Details

I. General information

NPI: 1518414606
Provider Name (Legal Business Name): EMMY LAURIE WEATHERS MSW, LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: EMMY LAURIE OLMSTEAD

II. Dates (important events)

Enumeration Date: 09/06/2016
Last Update Date: 09/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

413 N ALLUMBAUGH ST SUITE 101
BOISE ID
83704-9212
US

IV. Provider business mailing address

413 N ALLUMBAUGH ST SUITE 101
BOISE ID
83704-9212
US

V. Phone/Fax

Practice location:
  • Phone: 208-323-1125
  • Fax: 208-323-9604
Mailing address:
  • Phone: 208-323-1125
  • Fax: 208-323-9604

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLMSW-32291
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: