Healthcare Provider Details

I. General information

NPI: 1740110659
Provider Name (Legal Business Name): CLAY T BISTLINE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2026
Last Update Date: 05/21/2026
Certification Date: 05/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1276 W RIVER ST STE 100
BOISE ID
83702-7083
US

IV. Provider business mailing address

1276 W RIVER ST STE 100
BOISE ID
83702-7083
US

V. Phone/Fax

Practice location:
  • Phone: 208-338-4699
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: