Healthcare Provider Details

I. General information

NPI: 1902286099
Provider Name (Legal Business Name): JUSTIN HIROSHI HIRASAKI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2015
Last Update Date: 06/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

605 11TH AVE E
GOODING ID
83330-5368
US

IV. Provider business mailing address

842 JEFFERSON ST
MONTPELIER ID
83254-1452
US

V. Phone/Fax

Practice location:
  • Phone: 208-934-8461
  • Fax: 208-934-5437
Mailing address:
  • Phone: 808-277-8075
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number10267
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: