Provider Demographics
NPI:1619236494
Name:HORAN, MARIBETH
Entity Type:Individual
Prefix:
First Name:MARIBETH
Middle Name:
Last Name:HORAN
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 1:3228 E RIVERNEST LN
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-6928
Mailing Address - Country:US
Mailing Address - Phone:208-250-8418
Mailing Address - Fax:
Practice Address - Street 1:3228 E. RIVERNEST LANE
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706
Practice Address - Country:US
Practice Address - Phone:208-250-8418
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-14
Last Update Date:2012-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-4920106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist