Provider Demographics
NPI:1639054471
Name:VICINI, CATHLEEN (MFT, PSYD)
Entity type:Individual
Prefix:
First Name:CATHLEEN
Middle Name:
Last Name:VICINI
Suffix:
Gender:F
Credentials:MFT, PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12113 N UPPER RIDGE PL
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83714-9324
Mailing Address - Country:US
Mailing Address - Phone:707-888-8685
Mailing Address - Fax:
Practice Address - Street 1:1093 E IRON EAGLE DR STE 125
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-6004
Practice Address - Country:US
Practice Address - Phone:208-800-2207
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-11
Last Update Date:2025-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID3471962106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist