Healthcare Provider Details

I. General information

NPI: 1134965197
Provider Name (Legal Business Name): RUSTY JAMES WATTIER LMSW, ADC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2024
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

709 DEARBORN ST
CALDWELL ID
83605-4116
US

IV. Provider business mailing address

709 DEARBORN ST
CALDWELL ID
83605-4116
US

V. Phone/Fax

Practice location:
  • Phone: 208-606-9494
  • Fax:
Mailing address:
  • Phone: 208-606-9494
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number3581715
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: