Healthcare Provider Details

I. General information

NPI: 1245164128
Provider Name (Legal Business Name): STEPHEN CRANE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2026
Last Update Date: 06/09/2026
Certification Date: 06/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

412 E 41ST ST STE 2
GARDEN CITY ID
83714-6348
US

IV. Provider business mailing address

2611 W LEMP ST
BOISE ID
83702-2349
US

V. Phone/Fax

Practice location:
  • Phone: 208-996-3650
  • Fax:
Mailing address:
  • Phone: 208-996-3650
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number9481813
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: