Healthcare Provider Details

I. General information

NPI: 1811338148
Provider Name (Legal Business Name): PEAK RECOVERY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2013
Last Update Date: 04/14/2021
Certification Date: 04/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2423 S GEORGIA AVE
CALDWELL ID
83605-4477
US

IV. Provider business mailing address

2423 S GEORGIA AVE
CALDWELL ID
83605-4477
US

V. Phone/Fax

Practice location:
  • Phone: 208-455-1788
  • Fax: 208-455-2044
Mailing address:
  • Phone: 208-455-1788
  • Fax: 208-455-2044

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number151
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License NumberLPC-5173
License Number StateID

VIII. Authorized Official

Name: MICHONNE LEE PIEKMSA
Title or Position: OWNER
Credential: MS, , LPC ACADC
Phone: 208-455-1788