Healthcare Provider Details

I. General information

NPI: 1982439683
Provider Name (Legal Business Name): CLEAR MIND COUNSELING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/04/2024
Last Update Date: 09/04/2024
Certification Date: 09/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1765 W GOLF COURSE RD
COEUR D ALENE ID
83815-9033
US

IV. Provider business mailing address

1408 W TUALATIN DR
POST FALLS ID
83854-5185
US

V. Phone/Fax

Practice location:
  • Phone: 208-763-0606
  • Fax:
Mailing address:
  • Phone: 208-704-1617
  • Fax:

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 StateNULL
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: TYSON DURBIN
Title or Position: OWNER/THERAPIST
Credential: LPC,LMHC
Phone: 208-704-1617