Provider Demographics
NPI:1407679327
Name:HEYBORNE, AMITY (LPC)
Entity type:Individual
Prefix:
First Name:AMITY
Middle Name:
Last Name:HEYBORNE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:594 W KODIAK DR
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-8119
Mailing Address - Country:US
Mailing Address - Phone:208-954-1527
Mailing Address - Fax:
Practice Address - Street 1:211 E PINE AVE STE 106
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-2321
Practice Address - Country:US
Practice Address - Phone:208-954-1527
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-07
Last Update Date:2024-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-9513101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health