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General NPI Number Information
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NPI Number | 1982428306
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Entity Type | Organization
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Legal Business Name | INTENTIONAL SUPPORT, LLC
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Dates
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Enumeration Date | 11/12/2024
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Last Update Date | 11/12/2024
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Provider Practice Location Address
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Address Line | 5840 S MANDOLIN PL
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City | BOISE
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State | ID
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Zip | 83709-6377
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Country | US
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Telephone | 208-371-0641
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Fax |
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Provider Business Mailing Address
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Address Line | 5840 S MANDOLIN PL
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City | BOISE
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State | ID
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Zip | 83709-6377
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Country | US
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Telephone | 208-371-0641
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Fax |
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Authorized Official
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Title or Position | REGISTERED AGENT
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Name | KATIE J GULLICKSON
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Credential |
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Telephone | 208-371-0641
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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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