Healthcare Provider Details

I. General information

NPI: 1013745546
Provider Name (Legal Business Name): COMMONPLACE WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2024
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 W BANNOCK ST
BOISE ID
83702-5916
US

IV. Provider business mailing address

205 S BRUCE LN
BOISE ID
83712-7804
US

V. Phone/Fax

Practice location:
  • Phone: 208-329-8658
  • Fax: 208-473-7270
Mailing address:
  • Phone: 208-329-8658
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name: ISSA NTAKARUTIMANA
Title or Position: OWNER
Credential:
Phone: 208-329-8658