Healthcare Provider Details

I. General information

NPI: 1225952286
Provider Name (Legal Business Name): UP THE DRAW LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2026
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 RIVER ST
WALLACE ID
83873-2133
US

IV. Provider business mailing address

119 RIVER ST
WALLACE ID
83873-2133
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: HEATHER LEE BRANSTETTER
Title or Position: MANAGER
Credential:
Phone: 208-230-8454