Healthcare Provider Details

I. General information

NPI: 1336729474
Provider Name (Legal Business Name): EMILY PANTALEO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2021
Last Update Date: 04/13/2021
Certification Date: 04/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1031 W SANETTA ST
NAMPA ID
83651-5047
US

IV. Provider business mailing address

1044 NORTHWEST BLVD STE F
COEUR D ALENE ID
83814-2165
US

V. Phone/Fax

Practice location:
  • Phone: 208-466-7443
  • Fax:
Mailing address:
  • Phone: 727-800-2332
  • Fax: 727-800-2333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLMSW-40624
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: