Healthcare Provider Details

I. General information

NPI: 1861215295
Provider Name (Legal Business Name): SNAKE RIVER FAMILY SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2024
Last Update Date: 11/04/2024
Certification Date: 11/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

495 N SHILLING AVE
BLACKFOOT ID
83221-2336
US

IV. Provider business mailing address

495 N SHILLING AVE
BLACKFOOT ID
83221-2336
US

V. Phone/Fax

Practice location:
  • Phone: 435-744-3535
  • Fax:
Mailing address:
  • Phone: 435-744-3535
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DALLIN BEARD
Title or Position: COUNSELOR/OWNER
Credential: LPC
Phone: 435-744-3535