Healthcare Provider Details

I. General information

NPI: 1598959322
Provider Name (Legal Business Name): MOUNTAIN STATES COUNSELING & PSYCHOLOGICAL SERVICES PLLL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/05/2007
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 ALLUMBAUGH ST
BOISE ID
83704-9208
US

IV. Provider business mailing address

311 ALLUMBAUGH ST
BOISE ID
83704-9208
US

V. Phone/Fax

Practice location:
  • Phone: 208-375-6402
  • Fax: 208-323-1850
Mailing address:
  • Phone: 208-375-6402
  • Fax: 208-323-1850

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY61
License Number StateID

VIII. Authorized Official

Name: DR. CLAY H WARD
Title or Position: MANAGING PARTNER
Credential: PHD
Phone: 208-375-6402