Healthcare Provider Details

I. General information

NPI: 1104278142
Provider Name (Legal Business Name): SAFE HARBOR COUNSELING CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2016
Last Update Date: 04/26/2024
Certification Date: 04/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

206 W IRONWOOD DR # 1012
COEUR D ALENE ID
83814-2640
US

IV. Provider business mailing address

206 W IRONWOOD DR # 1012
COEUR D ALENE ID
83814-2640
US

V. Phone/Fax

Practice location:
  • Phone: 757-645-7722
  • Fax: 757-645-2808
Mailing address:
  • Phone: 757-645-7722
  • Fax: 757-645-2808

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0701005793
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number0717001312
License Number StateVA
# 4
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: LISA MARIE FRAZIER
Title or Position: OWNER/MANAGER
Credential: LPC, LMFT
Phone: 757-645-7722