Provider Demographics
NPI:1679969976
Name:CHIPPOLLA, MICHAEL (LCSW ACADC)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:CHIPPOLLA
Suffix:
Gender:M
Credentials:LCSW ACADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4477 W EMERALD ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-2000
Mailing Address - Country:US
Mailing Address - Phone:208-713-5250
Mailing Address - Fax:
Practice Address - Street 1:4477 W EMERALD ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-2000
Practice Address - Country:US
Practice Address - Phone:208-713-5250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-13
Last Update Date:2017-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDACADC-778101YA0400X
IDLCSW351261041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)