Healthcare Provider Details

I. General information

NPI: 1427651272
Provider Name (Legal Business Name): CHELSEA LYNN LEATHERMAN LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2020
Last Update Date: 11/16/2020
Certification Date: 11/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1032 S BRIDGEWAY PL # 110
EAGLE ID
83616-6099
US

IV. Provider business mailing address

6270 N PARK MEADOW WAY APT 102
BOISE ID
83713-1675
US

V. Phone/Fax

Practice location:
  • Phone: 208-246-0123
  • Fax: 208-246-0125
Mailing address:
  • Phone: 208-350-8877
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLPC-7818
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: