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General NPI Number Information
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NPI Number | 1306230958
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Entity Type | Organization
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Legal Business Name | NORTHEND WELLNESS, LLC
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Dates
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Enumeration Date | 03/21/2015
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Last Update Date | 06/28/2023
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Provider Practice Location Address
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Address Line | 1310 W HAYS ST
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City | BOISE
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State | ID
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Zip | 83702-5025
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Country | US
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Telephone | 208-949-6765
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Fax |
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Provider Business Mailing Address
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Address Line | 1310 W HAYS ST
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City | BOISE
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State | ID
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Zip | 83702-5025
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DAVID CUMMINS
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Credential |
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Telephone | 208-949-6765
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 202232
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License Number State | ID
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