Healthcare Provider Details

I. General information

NPI: 1982917472
Provider Name (Legal Business Name): PAULETTE A FLORES PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: PAULETTE A FLORES - ENRIQUEZ PH.D.

II. Dates (important events)

Enumeration Date: 07/26/2010
Last Update Date: 04/16/2020
Certification Date: 04/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2280 AMERICAN LEGION BLVD
MOUNTAIN HOME ID
83647-3142
US

IV. Provider business mailing address

2280 AMERICAN LEGION BLVD
MOUNTAIN HOME ID
83647-3142
US

V. Phone/Fax

Practice location:
  • Phone: 208-587-3988
  • Fax:
Mailing address:
  • Phone: 502-640-1902
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number130557
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY-203245
License Number StateID
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2011-78
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: