Healthcare Provider Details

I. General information

NPI: 1144544206
Provider Name (Legal Business Name): PETRA MORRISON LCPC, NCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/18/2010
Last Update Date: 04/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1031 W. SANETTA ST.
NAMPA ID
83651
US

IV. Provider business mailing address

2273 S VISTA AVE STE 190
BOISE ID
83705-7341
US

V. Phone/Fax

Practice location:
  • Phone: 208-466-7443
  • Fax:
Mailing address:
  • Phone: 208-343-2737
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberLCPC 5801
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: