Healthcare Provider Details

I. General information

NPI: 1366007775
Provider Name (Legal Business Name): CASE MANAGERS OF IDAHO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2019
Last Update Date: 05/16/2024
Certification Date: 05/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6003 W OVERLAND RD STE 201
BOISE ID
83709-3076
US

IV. Provider business mailing address

6003 W OVERLAND RD STE 201
BOISE ID
83709-3076
US

V. Phone/Fax

Practice location:
  • Phone: 208-801-6806
  • Fax: 208-694-6301
Mailing address:
  • Phone: 208-801-6806
  • Fax: 208-694-6301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name: MR. PATRICK KIRK
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 208-801-6806