Provider Demographics
NPI:1710279807
Name:ROOT, RACHEL ANNE (PHD)
Entity Type:Individual
Prefix:
First Name:RACHEL
Middle Name:ANNE
Last Name:ROOT
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:671 E RIVERPARK LN STE 220
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-6559
Mailing Address - Country:US
Mailing Address - Phone:208-344-2071
Mailing Address - Fax:208-344-2075
Practice Address - Street 1:671 E RIVERPARK LN STE 220
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706
Practice Address - Country:US
Practice Address - Phone:208-344-2071
Practice Address - Fax:208-344-2075
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-06
Last Update Date:2018-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPSY-202658103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID46-1124545OtherTAX ID
ID1710279807Medicaid
ID12239758OtherCAQH
ID1710279807Medicaid