Provider Demographics
NPI:1366164022
Name:WOLVERTON, MINDY JO (LMSW)
Entity type:Individual
Prefix:
First Name:MINDY
Middle Name:JO
Last Name:WOLVERTON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7580 W LOWER FORK CT
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-6088
Mailing Address - Country:US
Mailing Address - Phone:208-919-2886
Mailing Address - Fax:
Practice Address - Street 1:5440 W FRANKLIN RD STE 200
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-6434
Practice Address - Country:US
Practice Address - Phone:208-793-0004
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-19
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID285911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical