Healthcare Provider Details

I. General information

NPI: 1740117522
Provider Name (Legal Business Name): STATE OF IDAHO DEPARTMENT OF HEALTH AND WELFARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/06/2026
Last Update Date: 05/06/2026
Certification Date: 04/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 W STATE ST
BOISE ID
83702-6056
US

IV. Provider business mailing address

450 W STATE ST
BOISE ID
83702-6056
US

V. Phone/Fax

Practice location:
  • Phone: 208-475-2342
  • Fax:
Mailing address:
  • Phone: 208-475-2342
  • Fax: 208-475-2342

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MICHELLE S MATLOCK
Title or Position: FINANCIAL UNIT SUPERVISOR
Credential:
Phone: 208-475-2342