Healthcare Provider Details

I. General information

NPI: 1689158776
Provider Name (Legal Business Name): CURTIS MAHAN GARNER EDD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/24/2018
Last Update Date: 11/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

809 ASTOR AVE
NAMPA ID
83651-6516
US

IV. Provider business mailing address

809 ASTOR AVE
NAMPA ID
83651-6516
US

V. Phone/Fax

Practice location:
  • Phone: 208-407-4140
  • Fax:
Mailing address:
  • Phone: 208-407-4140
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLCPC3816
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY203043
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: