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General NPI Number Information
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NPI Number | 1952065294
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Entity Type | Organization
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Legal Business Name | PRACTICAL THERAPY LLC
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Dates
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Enumeration Date | 10/22/2021
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Last Update Date | 10/22/2021
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Provider Practice Location Address
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Address Line | 1111 S ORCHARD ST
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City | BOISE
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State | ID
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Zip | 83705-1966
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Country | US
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Telephone | 208-900-3678
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Fax |
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Provider Business Mailing Address
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Address Line | 9546 W MOSSYWOOD DR
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City | BOISE
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State | ID
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Zip | 83709-5333
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Country | US
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Telephone | 505-385-6305
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Fax |
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | TRAVIS THOMS
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Credential |
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Telephone | 505-385-6305
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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