=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548052723
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELSIRA CORAM
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/21/2025
-----------------------------------------------------
Last Update Date | 05/21/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2000 S EAGLE RD
-----------------------------------------------------
City | MERIDIAN
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83642-6707
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-623-8099
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7949 E TOUSSAND DR
-----------------------------------------------------
City | NAMPA
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83687-5175
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-392-0669
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 5171664
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------