=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043021702
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KIRI VAWDREY
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/14/2025
-----------------------------------------------------
Last Update Date | 01/14/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8620 W EMERALD ST STE 150
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83704-4839
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-617-3265
-----------------------------------------------------
Fax | 208-617-3270
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8620 W EMERALD ST STE 150
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83704-4839
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-617-3265
-----------------------------------------------------
Fax | 208-617-3270
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 1561272
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------