MEDICARE: ACTIVE PURSUIT THERAPY LLC

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
1	101YP2500X	Professional Counselor

General Provider Information

NPI Number	:	1154072023
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ACTIVE PURSUIT THERAPY LLC

Provider Business Mailing Address
First Line	:	10416 W PETEARANA ST
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83704-1251
Country	:	US
Telephone Number	:	120-831-6938
Fax Number	:

Provider Business Practice Location Address
First Line	:	3350 W AMERICANA TER STE 210B
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83706-2521
Country	:	US
Telephone Number	:	208-316-9381
Fax Number	:

Authorized Official
Title or Position	:	PROFESSIONAL COUNSELOR
Name	:	CANDACE RENEE COOPER
Credential	:	LCPC, NCC
Telephone Number	:	208-316-9381

Provider Enumeration Date	:	01/12/2022
Last Update Date	:	02/23/2022

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