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12553 W Explorer Dr Ste 190 Boise ID 83713-1612 | |
| (208) 376-7083 | |
| (208) 321-5069 |
| Full Name | |
|---|---|
| Speciality | Clinic/Center |
| Location | 12553 W Explorer Dr Ste 190, Boise, Idaho |
| Authorized Official Name and Position | Michelle Francesca Schaller (SENIOR DIRECTOR OF BH & RCM) |
| Authorized Official Contact | 7123558480 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
12553 W Explorer Dr Ste 190 Boise ID 83713-1612 Ph: (208) 376-7083 | 12553 W Explorer Dr Ste 190 Boise ID 83713-1612 Ph: (208) 376-7083 |
| NPI Number | 1194962829 |
|---|---|
| Provider Enumeration Date | 01/16/2009 |
| Last Update Date | 12/30/2024 |
| Certification Date | 12/30/2024 |
| Medicare PECOS PAC ID | 2163555053 |
|---|---|
| Medicare Enrollment ID | O20100728001248 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1194962829 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 101YA0400X | Counselor - Addiction (substance Use Disorder) | (* (Not Available)) | Secondary |
| 261QR0405X | Clinic/center - Rehabilitation, Substance Use Disorder | (Idaho) | Primary |
| Provider Name | Amy K Jeppesen |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1467605642 PECOS PAC ID: 7618000381 Enrollment ID: I20100810001115 |
| Provider Name | Michael L Larocco |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1720319916 PECOS PAC ID: 7012190556 Enrollment ID: I20110322000312 |
| Provider Name | Cassi E Shelly |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1477994994 PECOS PAC ID: 8224267869 Enrollment ID: I20140131000774 |
| Provider Name | Nina Abul-husn |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1538421094 PECOS PAC ID: 9133366990 Enrollment ID: I20170725003982 |
| Provider Name | Kersondra Corrine Hood |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1598278673 PECOS PAC ID: 0244661825 Enrollment ID: I20200514002555 |
| Provider Name | Sarah E Samson |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1144881418 PECOS PAC ID: 7517398019 Enrollment ID: I20200518001666 |
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