Healthcare Provider Details

I. General information

NPI: 1487368759
Provider Name (Legal Business Name): MICHAELLA A. HAMMERSBERG LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/10/2023
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30410 HIGHWAY 200 STE 200R-3
PONDERAY ID
83852-9601
US

IV. Provider business mailing address

30410 HIGHWAY 200 STE 200R-3
PONDERAY ID
83852-9601
US

V. Phone/Fax

Practice location:
  • Phone: 208-620-4861
  • Fax:
Mailing address:
  • Phone: 208-620-4861
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLCSW-8911188
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: