Healthcare Provider Details

I. General information

NPI: 1841091295
Provider Name (Legal Business Name): HEATHER LEE BRANSTETTER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2025
Last Update Date: 03/28/2025
Certification Date: 03/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 E MULLAN AVE
OSBURN ID
83849-0480
US

IV. Provider business mailing address

119 RIVER ST
WALLACE ID
83873-2133
US

V. Phone/Fax

Practice location:
  • Phone: 208-261-1158
  • Fax:
Mailing address:
  • Phone: 208-230-8454
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number3371056
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: