Provider Demographics
NPI:1982271615
Name:ROYLANCE, ADISSON D
Entity type:Individual
Prefix:
First Name:ADISSON
Middle Name:D
Last Name:ROYLANCE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8050 W RIFLEMAN ST STE 100
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-9006
Mailing Address - Country:US
Mailing Address - Phone:208-985-3052
Mailing Address - Fax:
Practice Address - Street 1:8050 W RIFLEMAN ST STE 100
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-9006
Practice Address - Country:US
Practice Address - Phone:208-985-3052
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-10
Last Update Date:2024-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
IDLCPC-10523101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No171M00000XOther Service ProvidersCase Manager/Care Coordinator