Healthcare Provider Details

I. General information

NPI: 1326466988
Provider Name (Legal Business Name): PATHWAYS OF IDAHO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/01/2014
Last Update Date: 06/20/2024
Certification Date: 05/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

545 N BENJAMIN LN STE 185
BOISE ID
83704-9625
US

IV. Provider business mailing address

545 N BENJAMIN LN STE 185
BOISE ID
83704-9625
US

V. Phone/Fax

Practice location:
  • Phone: 208-322-1026
  • Fax: 208-322-1029
Mailing address:
  • Phone: 208-322-1026
  • Fax: 208-322-1029

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health 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: MR. RYAN JONES
Title or Position: IDAHO STATE DIRECTOR
Credential:
Phone: 208-322-1026