=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427854751
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AMY ABSALONSON PLAY THERAPY AND COUNSELING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/19/2025
-----------------------------------------------------
Last Update Date | 02/19/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6428 W. INTERCHANGE LANE
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83709-8370
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-502-8126
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1857 N ARONMINK WAY
-----------------------------------------------------
City | MERIDIAN
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83646-1162
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-860-4452
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | AMY ABSALONSON
-----------------------------------------------------
Credential | LCPC
-----------------------------------------------------
Telephone | 208-502-8126
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------