Healthcare Provider Details

I. General information

NPI: 1750205357
Provider Name (Legal Business Name): ERIKA WASSOM
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2026
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 S ORCHARD ST STE 110
BOISE ID
83705-1961
US

IV. Provider business mailing address

896 S LOCUST GROVE RD
MERIDIAN ID
83642-6204
US

V. Phone/Fax

Practice location:
  • Phone: 208-919-4692
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number4381914
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: