Provider Demographics
NPI:1619791183
Name:MOORHEAD, EMILY
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:MOORHEAD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3324 N LAKEHARBOR LN # G-203
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83703-6255
Mailing Address - Country:US
Mailing Address - Phone:907-441-6373
Mailing Address - Fax:
Practice Address - Street 1:1276 W RIVER ST STE 100
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-7083
Practice Address - Country:US
Practice Address - Phone:208-338-4699
Practice Address - Fax:208-322-4722
Is Sole Proprietor?:No
Enumeration Date:2024-11-12
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID4761577101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health