Healthcare Provider Details

I. General information

NPI: 1457280521
Provider Name (Legal Business Name): MELISSA CROOKS BENNETT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2026
Last Update Date: 05/15/2026
Certification Date: 05/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 11TH AVE S STE 205
NAMPA ID
83651-5074
US

IV. Provider business mailing address

4007 E HAGS HEAD ST
NAMPA ID
83686-3907
US

V. Phone/Fax

Practice location:
  • Phone: 657-763-6614
  • Fax: 208-279-0222
Mailing address:
  • Phone: 657-763-6614
  • Fax: 208-279-0222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: