Healthcare Provider Details

I. General information

NPI: 1164550455
Provider Name (Legal Business Name): IDAHO DEPT OF HEALTH & WELFARE REG 1 CMH PSR CDA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 IRONWOOD DR STE 100
COEUR D ALENE ID
83814-2628
US

IV. Provider business mailing address

1250 IRONWOOD DR STE 100
COEUR D ALENE ID
83814-2628
US

V. Phone/Fax

Practice location:
  • Phone: 208-769-1515
  • Fax: 208-666-6744
Mailing address:
  • Phone: 208-769-1515
  • Fax: 208-666-6744

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CORA JO GUSSENHOVEN
Title or Position: PROGRAM MANAGER
Credential:
Phone: 208-769-1406