Provider Demographics
NPI:1407283393
Name:PIEKSMA, MICHONNE
Entity Type:Individual
Prefix:
First Name:MICHONNE
Middle Name:
Last Name:PIEKSMA
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 1:2423 S GEORGIA AVE
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83605-4477
Mailing Address - Country:US
Mailing Address - Phone:208-455-1788
Mailing Address - Fax:208-455-2044
Practice Address - Street 1:2423 S GEORGIA AVE
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-4477
Practice Address - Country:US
Practice Address - Phone:208-455-1788
Practice Address - Fax:208-455-2044
Is Sole Proprietor?:No
Enumeration Date:2013-10-09
Last Update Date:2013-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-5173101YA0400X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDLPC-5173Medicaid