Healthcare Provider Details

I. General information

NPI: 1235791997
Provider Name (Legal Business Name): METAMORPHOSIS COUNSELING AND HEALTH CENTER OF IDAHO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2019
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

10108 W OVERLAND RD # A
BOISE ID
83709-1428
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 TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL
# 7
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateNULL

VIII. Authorized Official

Name: MRS. CRYSTAL MICHELLE MILLER
Title or Position: EXECUTIVE DIRECTOR/OWNER
Credential: BS
Phone: 208-376-1532