Healthcare Provider Details

I. General information

NPI: 1477049492
Provider Name (Legal Business Name): IDAHO TRAUMA THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2018
Last Update Date: 07/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6126 W STATE ST STE 109
BOISE ID
83703-2741
US

IV. Provider business mailing address

6126 W STATE ST STE 109
BOISE ID
83703-2741
US

V. Phone/Fax

Practice location:
  • Phone: 208-391-2957
  • Fax:
Mailing address:
  • Phone: 208-391-2957
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License NumberLPC-6772
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License NumberLPC-6772
License Number StateID
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License NumberLPC-6772
License Number StateID

VIII. Authorized Official

Name: MRS. HILLARY DAWN COOK
Title or Position: OWNER
Credential: LPC
Phone: 208-391-2957