Provider Demographics
NPI:1053043307
Name:YOUNG, HEATHER
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:YOUNG
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:PO BOX 454
Mailing Address - Street 2:
Mailing Address - City:IDAHO CITY
Mailing Address - State:ID
Mailing Address - Zip Code:83631-0454
Mailing Address - Country:US
Mailing Address - Phone:512-337-6685
Mailing Address - Fax:
Practice Address - Street 1:1673 W SHORELINE DR
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-6750
Practice Address - Country:US
Practice Address - Phone:208-261-1157
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-27
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID42292104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker