Healthcare Provider Details

I. General information

NPI: 1003103458
Provider Name (Legal Business Name): JOHNNY JOSIAH MEEHAN LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2011
Last Update Date: 05/17/2022
Certification Date: 05/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6855 W FAIRVIEW AVE
BOISE ID
83704-8046
US

IV. Provider business mailing address

PO BOX 9
NAMPA ID
83653-0009
US

V. Phone/Fax

Practice location:
  • Phone: 208-323-9600
  • Fax: 208-323-9606
Mailing address:
  • Phone: 208-467-4431
  • Fax: 208-466-5359

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-42126
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: