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NPI Code Detail

MEDICARE: MR. RUSTY JAMES WATTIER LMSW, ADC

MEDICARE: MR. RUSTY JAMES WATTIER LMSW, ADC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1104100000XSocial Worker3581715ID
2101YA0400XAddiction (Substance Use Disorder) CounselorID

General Provider Information

NPI Number : 1134965197
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. RUSTY JAMES WATTIER LMSW, ADC
Provider Business Mailing Address
First Line : 709 DEARBORN ST
Second Line :
City : CALDWELL
State : ID
Zip : 83605-4116
Country : US
Telephone Number : 208-606-9494
Fax Number :
Provider Business Practice Location Address
First Line : 709 DEARBORN ST
Second Line :
City : CALDWELL
State : ID
Zip : 83605-4116
Country : US
Telephone Number : 208-606-9494
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/08/2024
Last Update Date : 06/11/2026

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