Healthcare Provider Details

I. General information

NPI: 1053053736
Provider Name (Legal Business Name): PRIMARY BEHAVIORAL HEALTH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2022
Last Update Date: 05/11/2022
Certification Date: 05/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8620 W EMERALD ST STE 170
BOISE ID
83704-4827
US

IV. Provider business mailing address

8620 W EMERALD ST STE 170
BOISE ID
83704-4827
US

V. Phone/Fax

Practice location:
  • Phone: 208-713-1065
  • Fax:
Mailing address:
  • Phone: 208-713-1065
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: KRISTI OLSON
Title or Position: OWNER
Credential:
Phone: 208-713-1065