Provider Demographics
NPI:1316714843
Name:HALLENBERGER, RANDAL (LSW)
Entity type:Individual
Prefix:
First Name:RANDAL
Middle Name:
Last Name:HALLENBERGER
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1276 W RIVER ST STE 100
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-7083
Mailing Address - Country:US
Mailing Address - Phone:208-608-9058
Mailing Address - Fax:208-344-0127
Practice Address - Street 1:1276 W RIVER ST STE 100
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-7083
Practice Address - Country:US
Practice Address - Phone:208-608-9058
Practice Address - Fax:208-344-0127
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-05
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLSW-25776104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker