Healthcare Provider Details

I. General information

NPI: 1427813658
Provider Name (Legal Business Name): BODHICITTA COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/16/2024
Last Update Date: 02/16/2024
Certification Date: 02/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 NORTHWEST BLVD
COEUR D ALENE ID
83814-2974
US

IV. Provider business mailing address

9030 N HESS ST # 104
HAYDEN ID
83835-9827
US

V. Phone/Fax

Practice location:
  • Phone: 208-929-6845
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: GREG LIPPERT
Title or Position: OWNER
Credential: LCPC
Phone: 208-929-6845