Provider Demographics
NPI:1619760501
Name:DYNOVION COGNITIVE WELLNESS, LLC
Entity type:Organization
Organization Name:DYNOVION COGNITIVE WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:J
Authorized Official - Last Name:HOEKSTRA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-964-7189
Mailing Address - Street 1:14233 SILVER RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83607-5448
Mailing Address - Country:US
Mailing Address - Phone:208-964-7189
Mailing Address - Fax:
Practice Address - Street 1:12550 W EXPLORER DR
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-1826
Practice Address - Country:US
Practice Address - Phone:986-230-2245
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-05-23
Last Update Date:2025-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty