Healthcare Provider Details

I. General information

NPI: 1619988979
Provider Name (Legal Business Name): FAMILY PATHWAYS COOPERATIVE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2006
Last Update Date: 10/23/2023
Certification Date: 10/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34 LOUELLA ST
BLACKFOOT ID
83221-1609
US

IV. Provider business mailing address

34 LOUELLA ST
BLACKFOOT ID
83221-1609
US

V. Phone/Fax

Practice location:
  • Phone: 208-782-1322
  • Fax: 208-782-1322
Mailing address:
  • Phone: 208-782-1322
  • Fax: 208-782-1322

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State

VIII. Authorized Official

Name: SANDEE K. YOUNG
Title or Position: ADMINISTRATOR
Credential: LCSW
Phone: 208-782-1322