Healthcare Provider Details

I. General information

NPI: 1558954719
Provider Name (Legal Business Name): MELISSA ANDRUSHKO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/18/2021
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1731 W HENRYS FORK DR
MERIDIAN ID
83642-7323
US

IV. Provider business mailing address

1731 W HENRYS FORK DR
MERIDIAN ID
83642-7323
US

V. Phone/Fax

Practice location:
  • Phone: 208-539-8849
  • Fax:
Mailing address:
  • Phone: 208-736-5048
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6381120
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: