Healthcare Provider Details

I. General information

NPI: 1053734251
Provider Name (Legal Business Name): SEQUEL ALLIANCE FAMILY SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2014
Last Update Date: 01/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 W IRONWOOD DR STE 101
COEUR D ALENE ID
83814-2660
US

IV. Provider business mailing address

1131 EAGLETREE LN SW
HUNTSVILLE AL
35801-6478
US

V. Phone/Fax

Practice location:
  • Phone: 208-664-9729
  • Fax: 208-665-5735
Mailing address:
  • Phone: 256-880-3339
  • Fax: 256-880-9569

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MS. MARY E CAUDLE
Title or Position: CBO DIRECTOR OF PATIENT ACCOUNTS
Credential:
Phone: 256-880-3339