Healthcare Provider Details

I. General information

NPI: 1003145533
Provider Name (Legal Business Name): AMBITIONS OF IDAHO, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2009
Last Update Date: 10/12/2023
Certification Date: 10/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1044 NORTHWEST BLVD STE C
COEUR D ALENE ID
83814-2114
US

IV. Provider business mailing address

1044 NORTHWEST BLVD STE C
COEUR D ALENE ID
83814-2114
US

V. Phone/Fax

Practice location:
  • Phone: 208-930-1740
  • Fax: 208-930-1695
Mailing address:
  • Phone: 208-930-1740
  • Fax: 208-930-1695

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: SHANE HAGEL
Title or Position: PRESIDENT
Credential:
Phone: 208-930-1740