Healthcare Provider Details

I. General information

NPI: 1316690696
Provider Name (Legal Business Name): CHRISTOPHER DANIEL BENNETT LCPC, NCC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2022
Last Update Date: 01/29/2024
Certification Date: 01/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13900 PLEASANT VLY RD
KUNA ID
83634-2723
US

IV. Provider business mailing address

13900 PLEASANT VLY RD
KUNA ID
83634-2723
US

V. Phone/Fax

Practice location:
  • Phone: 208-336-1260
  • Fax:
Mailing address:
  • Phone: 208-336-1260
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6357
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: