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General NPI Number Information
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NPI Number | 1154072023
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Entity Type | Organization
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Legal Business Name | ACTIVE PURSUIT THERAPY LLC
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Dates
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Enumeration Date | 01/12/2022
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Last Update Date | 02/23/2022
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Provider Practice Location Address
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Address Line | 3350 W AMERICANA TER STE 210B
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City | BOISE
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State | ID
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Zip | 83706-2521
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Country | US
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Telephone | 208-316-9381
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Fax |
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Provider Business Mailing Address
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Address Line | 10416 W PETEARANA ST
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City | BOISE
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State | ID
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Zip | 83704-1251
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Country | US
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Telephone | 120-831-6938
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Fax |
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Authorized Official
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Title or Position | PROFESSIONAL COUNSELOR
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Name | CANDACE RENEE COOPER
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Credential | LCPC, NCC
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Telephone | 208-316-9381
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number |
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License Number State |
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