Healthcare Provider Details

I. General information

NPI: 1902716038
Provider Name (Legal Business Name): PINE COUNSELING, LCSW, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

930 N 6TH E
MOUNTAIN HOME ID
83647-2208
US

IV. Provider business mailing address

999 W MAIN ST STE 100
BOISE ID
83702-9001
US

V. Phone/Fax

Practice location:
  • Phone: 208-407-4728
  • Fax:
Mailing address:
  • Phone: 406-303-1882
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: COLTEN YOUNG SICARD
Title or Position: OWNER
Credential: LCSW
Phone: 208-407-4728