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General NPI Number Information
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NPI Number | 1295559797
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Entity Type | Organization
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Legal Business Name | GREATER MIND INTEGRATION, PLLC
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Dates
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Enumeration Date | 11/12/2024
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Last Update Date | 11/12/2024
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Provider Practice Location Address
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Address Line | 3350 W AMERICANA TER STE 330C
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City | BOISE
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State | ID
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Zip | 83706-2547
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Country | US
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Telephone | 208-273-3514
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Fax | 208-593-4357
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Provider Business Mailing Address
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Address Line | 2800 N BOGUS BASIN RD APT D103
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City | BOISE
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State | ID
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Zip | 83702-0976
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Country | US
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Telephone | 208-866-3971
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Fax |
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Authorized Official
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Title or Position | OWNER/PROVIDER
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Name | TRACY LYNN ROE
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Credential | LCPC
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Telephone | 208-866-3971
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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