Provider Demographics
NPI:1619001005
Name:ETNYRE, ALLISON LEE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:ALLISON
Middle Name:LEE
Last Name:ETNYRE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11368 W HICKORY BARK DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-1004
Mailing Address - Country:US
Mailing Address - Phone:208-323-9698
Mailing Address - Fax:
Practice Address - Street 1:1070 N CURTIS RD
Practice Address - Street 2:SUITE 210
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-1238
Practice Address - Country:US
Practice Address - Phone:208-860-0770
Practice Address - Fax:208-322-0367
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPSY-202238103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDN6135OtherBLUE CROSS
ID000010158559OtherREGENCE BLUE SHIELD
ID002269500Medicaid