Healthcare Provider Details

I. General information

NPI: 1700327863
Provider Name (Legal Business Name): NICOLE STILL LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2017
Last Update Date: 03/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2076 SOUTH EAGLE ROAD
MERIDIAN ID
83642
US

IV. Provider business mailing address

2874 E. NAHUATL DRIVE
BOISE ID
83716
US

V. Phone/Fax

Practice location:
  • Phone: 208-955-7333
  • Fax:
Mailing address:
  • Phone: 208-918-7899
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLCPC-6442
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: