Healthcare Provider Details

I. General information

NPI: 1508484312
Provider Name (Legal Business Name): PETE SERRA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2020
Last Update Date: 07/08/2020
Certification Date: 07/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1031 W SANETTA ST
NAMPA ID
83651-5047
US

IV. Provider business mailing address

12634 W KEMPSHIRE CT
STAR ID
83669-5145
US

V. Phone/Fax

Practice location:
  • Phone: 208-466-7443
  • Fax:
Mailing address:
  • Phone: 208-447-9967
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: