Provider Demographics
NPI:1548980139
Name:VIRGINIA SPACKMAN LLC
Entity type:Organization
Organization Name:VIRGINIA SPACKMAN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VIRGINIA
Authorized Official - Middle Name:L
Authorized Official - Last Name:SPACKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MED, LCPC
Authorized Official - Phone:208-409-3050
Mailing Address - Street 1:1068 OWYHEE ST
Mailing Address - Street 2:
Mailing Address - City:KUNA
Mailing Address - State:ID
Mailing Address - Zip Code:83634-2206
Mailing Address - Country:US
Mailing Address - Phone:208-409-3050
Mailing Address - Fax:
Practice Address - Street 1:1068 OWYHEE ST
Practice Address - Street 2:
Practice Address - City:KUNA
Practice Address - State:ID
Practice Address - Zip Code:83634-2206
Practice Address - Country:US
Practice Address - Phone:208-409-3050
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-01
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty