Healthcare Provider Details

I. General information

NPI: 1689065765
Provider Name (Legal Business Name): EMMA ORTHEL LCP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/11/2015
Last Update Date: 02/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2240 AMERICAN LEGION BLVD
MOUNTAIN HOME ID
83647
US

IV. Provider business mailing address

2240 AMERICAN LEGION
MOUNTAIN HOME ID
83647
US

V. Phone/Fax

Practice location:
  • Phone: 208-580-9525
  • Fax: 208-580-9527
Mailing address:
  • Phone: 208-580-9525
  • Fax: 208-580-9527

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC-5737
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: