Provider Demographics
NPI:1083776256
Name:MORRISSETTE, MATTHEW P (LCPC)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:P
Last Name:MORRISSETTE
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13601 W MCMILLAN RD STE 102-224
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-2025
Mailing Address - Country:US
Mailing Address - Phone:208-914-8080
Mailing Address - Fax:
Practice Address - Street 1:943 W. OVERLAND RD.
Practice Address - Street 2:STE 126
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-8600
Practice Address - Country:US
Practice Address - Phone:208-926-2046
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-2797101YM0800X
IDLCPC-3444101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010157489OtherREGENCE BLUE SHIELD
IDQ7362OtherBLUE CROSS OF IDAHO