Healthcare Provider Details

I. General information

NPI: 1407638992
Provider Name (Legal Business Name): METAMORPHOSIS HEALTH, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2023
Last Update Date: 11/08/2023
Certification Date: 11/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10108 W OVERLAND RD STE A
BOISE ID
83709-1428
US

IV. Provider business mailing address

2118 N AZURITE DR
KUNA ID
83634-4904
US

V. Phone/Fax

Practice location:
  • Phone: 208-376-1532
  • Fax: 208-375-7251
Mailing address:
  • Phone: 208-376-1532
  • Fax: 208-375-7251

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. CRYSTAL MICHELLE MILLER
Title or Position: CEO/OWNER
Credential:
Phone: 208-890-6205