Healthcare Provider Details

I. General information

NPI: 1245948819
Provider Name (Legal Business Name): SUSAN MARTIN THERAPY AND WELLNESS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/11/2022
Last Update Date: 11/11/2022
Certification Date: 10/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9474 W FAIRVIEW AVE
BOISE ID
83704-8101
US

IV. Provider business mailing address

PO BOX 140514
BOISE ID
83714-0514
US

V. Phone/Fax

Practice location:
  • Phone: 208-629-7730
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SUSAN MARTIN
Title or Position: OWNER
Credential: MA, LMFT
Phone: 208-629-7730