Healthcare Provider Details

I. General information

NPI: 1871005108
Provider Name (Legal Business Name): KATHRYN R HEYDORN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/26/2017
Last Update Date: 02/14/2024
Certification Date: 02/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7714 E WILLARD DR
NAMPA ID
83687-8252
US

IV. Provider business mailing address

7714 E WILLARD DR
NAMPA ID
83687-8252
US

V. Phone/Fax

Practice location:
  • Phone: 208-810-1276
  • Fax: 208-895-8049
Mailing address:
  • Phone: 208-810-1276
  • Fax: 208-895-8049

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberMC60789946
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMG60789946
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: