=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790659480
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BOISE HOLISTIC THERAPY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/03/2025
-----------------------------------------------------
Last Update Date | 10/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2411 W STATE ST
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83702-3164
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-891-0316
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 112 PROSPECTOR LN
-----------------------------------------------------
City | IDAHO CITY
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83631-7701
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-891-0316
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KRISTIE LOUDERBOUGH
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 208-891-0316
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------