Healthcare Provider Details

I. General information

NPI: 1801000112
Provider Name (Legal Business Name): ALTA ADDICTIONS AND MENTAL HEALTH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2007
Last Update Date: 06/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5223 W OVERLAND RD
BOISE ID
83705-2637
US

IV. Provider business mailing address

5223 W OVERLAND RD
BOISE ID
83705-2637
US

V. Phone/Fax

Practice location:
  • Phone: 208-395-1713
  • Fax: 208-395-1715
Mailing address:
  • Phone: 208-395-1713
  • Fax: 208-395-1715

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License NumberLCSW 1100
License Number StateID

VIII. Authorized Official

Name: MS. LESA MCCONNEL
Title or Position: CLINICAL DIRECTOR
Credential: LCSW
Phone: 208-395-1713