Healthcare Provider Details

I. General information

NPI: 1962312876
Provider Name (Legal Business Name): MADISON FERRIS LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2026
Last Update Date: 09/11/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 PICABO STREET, UNIT 102
KETCHUM ID
83340
US

IV. Provider business mailing address

PO BOX 4486
KETCHUM ID
83340-4600
US

V. Phone/Fax

Practice location:
  • Phone: 208-309-2815
  • Fax:
Mailing address:
  • Phone: 208-309-2815
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number7881318
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: