Healthcare Provider Details

I. General information

NPI: 1770369779
Provider Name (Legal Business Name): SAMANTHA DINGMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2023
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

317 W 6TH ST STE 208
MOSCOW ID
83843-2387
US

IV. Provider business mailing address

702 RACHEL ST
TROY ID
83871-9668
US

V. Phone/Fax

Practice location:
  • Phone: 208-882-3504
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number8311991
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: