Provider Demographics
NPI:1891389870
Name:KISHPAUGH, DREW WILLIAM
Entity Type:Individual
Prefix:
First Name:DREW
Middle Name:WILLIAM
Last Name:KISHPAUGH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8020 W DORIAN ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-2713
Mailing Address - Country:US
Mailing Address - Phone:208-850-4811
Mailing Address - Fax:
Practice Address - Street 1:8020 W DORIAN ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-2713
Practice Address - Country:US
Practice Address - Phone:208-850-4811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-21
Last Update Date:2021-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician