Healthcare Provider Details

I. General information

NPI: 1720967243
Provider Name (Legal Business Name): LEISA RHEAD MSW GRADUATE STUDENT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2025
Last Update Date: 09/02/2025
Certification Date: 09/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1065 E WINDING CREEK DR STE 250
EAGLE ID
83616-7246
US

IV. Provider business mailing address

7925 W MIRROR POND DR
BOISE ID
83714-2275
US

V. Phone/Fax

Practice location:
  • Phone: 208-805-2324
  • Fax:
Mailing address:
  • Phone: 208-420-7154
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: