Healthcare Provider Details

I. General information

NPI: 1659192292
Provider Name (Legal Business Name): UP NORTH COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2024
Last Update Date: 10/17/2024
Certification Date: 10/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 N LAKEWOOD DR STE 225
COEUR D ALENE ID
83814-2473
US

IV. Provider business mailing address

2101 N LAKEWOOD DR STE 225
COEUR D ALENE ID
83814-2473
US

V. Phone/Fax

Practice location:
  • Phone: 208-984-0989
  • Fax: 208-601-6133
Mailing address:
  • Phone: 208-984-0989
  • Fax: 208-601-6133

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: EMILY STADSTAD
Title or Position: OWNER
Credential: LMFT
Phone: 208-984-0989