Provider Demographics
NPI:1518588375
Name:CRIST, HEATHER MOSQUEDA
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:MOSQUEDA
Last Name:CRIST
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 1:6322 W ROBERTSON DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-2173
Mailing Address - Country:US
Mailing Address - Phone:208-571-9709
Mailing Address - Fax:
Practice Address - Street 1:270 W GEORGIA AVE
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-2835
Practice Address - Country:US
Practice Address - Phone:208-463-0212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-04
Last Update Date:2020-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-39389104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker