Healthcare Provider Details

I. General information

NPI: 1689313462
Provider Name (Legal Business Name): AUTUMN EDJ ALLBERT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2022
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

524 S 9TH AVE STE 103
CALDWELL ID
83605-5072
US

IV. Provider business mailing address

PO BOX 112
NEW PLYMOUTH ID
83655-0112
US

V. Phone/Fax

Practice location:
  • Phone: 208-454-8555
  • Fax:
Mailing address:
  • Phone: 208-697-2450
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberRBT-22-203613
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-22-203613
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: