Healthcare Provider Details

I. General information

NPI: 1609170471
Provider Name (Legal Business Name): PALADIN SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/07/2011
Last Update Date: 11/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1042 W MILL AVE # 205
COEUR D ALENE ID
83814-2489
US

IV. Provider business mailing address

1042 W MILL AVE # 205
COEUR D ALENE ID
83814-2489
US

V. Phone/Fax

Practice location:
  • Phone: 208-659-3527
  • Fax: 208-292-4544
Mailing address:
  • Phone: 208-659-3527
  • Fax: 208-292-4544

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License NumberLCSW-26516
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW26516
License Number StateID

VIII. Authorized Official

Name: JEFF K WILLIAMS
Title or Position: OWNER
Credential: LCSW
Phone: 208-659-3527