Healthcare Provider Details

I. General information

NPI: 1902771678
Provider Name (Legal Business Name): SNAKE RIVER PSYCHIATRY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2025
Last Update Date: 10/10/2025
Certification Date: 10/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13972 TRAPPER LN
CALDWELL ID
83607-5481
US

IV. Provider business mailing address

13972 TRAPPER LN
CALDWELL ID
83607-5481
US

V. Phone/Fax

Practice location:
  • Phone: 208-906-4073
  • Fax:
Mailing address:
  • Phone: 208-906-4073
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: SEAN HAGGERTY
Title or Position: SOLE MEMBER
Credential: PMHNP-BC
Phone: 208-906-4073