Healthcare Provider Details

I. General information

NPI: 1851939474
Provider Name (Legal Business Name): KHADIJA TAHIRA EWALT LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2019
Last Update Date: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4116 SAYLOR LN UNIT B
CALDWELL ID
83607-1096
US

IV. Provider business mailing address

4116 SAYLOR LN UNIT B
CALDWELL ID
83607-1096
US

V. Phone/Fax

Practice location:
  • Phone: 435-572-0340
  • Fax:
Mailing address:
  • Phone: 435-572-0340
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLH61625777
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: