Healthcare Provider Details

I. General information

NPI: 1700129491
Provider Name (Legal Business Name): HUMAN SUPPORTS OF IDAHO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/01/2013
Last Update Date: 12/23/2025
Certification Date: 12/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

206 E ELM ST
CALDWELL ID
83605-4815
US

IV. Provider business mailing address

4477 W EMERALD ST STE C100
BOISE ID
83706-2058
US

V. Phone/Fax

Practice location:
  • Phone: 208-454-8389
  • Fax: 208-454-8404
Mailing address:
  • Phone: 208-321-0160
  • Fax: 208-321-0221

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: ALITA RUBY
Title or Position: ADMINISTRATIVE SERVICE MANAGER
Credential:
Phone: 208-454-8389