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General NPI Number Information
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NPI Number | 1861837601
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Entity Type | Individual
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Provider Name | TIMOTHY STEPHEN DESANTIS LCPC
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Gender | Male
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Dates
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Enumeration Date | 05/07/2013
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Last Update Date | 05/07/2013
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Provider Practice Location Address
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Address Line | 8620 W EMERALD ST SUITE 150
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City | BOISE
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State | ID
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Zip | 83704-4824
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Country | US
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Telephone | 208-672-2900
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Fax | 208-672-2919
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Provider Business Mailing Address
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Address Line | 1410 CHELSEY CIR
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City | MOUNTAIN HOME
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State | ID
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Zip | 83647-4634
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Country | US
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Telephone | 208-672-8764
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | LCPC-4671
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License Number State | ID
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