Healthcare Provider Details

I. General information

NPI: 1902526999
Provider Name (Legal Business Name): EMILY A BALLANTYNE LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: EMILY A GALEGO

II. Dates (important events)

Enumeration Date: 08/30/2022
Last Update Date: 03/31/2025
Certification Date: 03/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11513 W FAIRVIEW AVE STE 105
BOISE ID
83713-7887
US

IV. Provider business mailing address

11513 W FAIRVIEW AVE STE 105
BOISE ID
83713-7887
US

V. Phone/Fax

Practice location:
  • Phone: 209-908-7882
  • Fax:
Mailing address:
  • Phone: 208-908-7882
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number42611
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: