Healthcare Provider Details

I. General information

NPI: 1083977656
Provider Name (Legal Business Name): HIGHER GROUND RETREAT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2012
Last Update Date: 06/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17626 DEER FLAT RD
CALDWELL ID
83607-9779
US

IV. Provider business mailing address

17626 DEER FLAT RD
CALDWELL ID
83607-9779
US

V. Phone/Fax

Practice location:
  • Phone: 855-497-4763
  • Fax:
Mailing address:
  • Phone: 855-497-4763
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License NumberLCSW 1159
License Number StateID

VIII. Authorized Official

Name: MS. BEATRICE SUSAN CARROLL
Title or Position: EXECUTIVE DIRECTOR
Credential: LCSW, LMFT
Phone: 208-440-7009