Provider Demographics
NPI:1780286294
Name:RIRIE, MIKAYLA ELIZABETH (BS)
Entity type:Individual
Prefix:
First Name:MIKAYLA
Middle Name:ELIZABETH
Last Name:RIRIE
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8918 W NORTHVIEW ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-7017
Mailing Address - Country:US
Mailing Address - Phone:208-421-6612
Mailing Address - Fax:
Practice Address - Street 1:8918 W NORTHVIEW ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-7017
Practice Address - Country:US
Practice Address - Phone:208-421-6612
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-10
Last Update Date:2023-05-12
Deactivation Date:2021-10-07
Deactivation Code:
Reactivation Date:2021-10-26
Provider Licenses
StateLicense IDTaxonomies
251S00000X, 171M00000X, 101YA0400X, 251B00000X
IDLPC-9497101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No251S00000XAgenciesCommunity/Behavioral Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No251B00000XAgenciesCase Management