Healthcare Provider Details

I. General information

NPI: 1720141906
Provider Name (Legal Business Name): DIVERSIFIED SOCIAL SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5624 N GOVERNMENT WAY STE 7B
DALTON GARDENS ID
83815-7350
US

IV. Provider business mailing address

5624 N GOVERNMENT WAY STE 7B
DALTON GARDENS ID
83815-7350
US

V. Phone/Fax

Practice location:
  • Phone: 208-762-9890
  • Fax: 208-762-9892
Mailing address:
  • Phone: 208-762-9890
  • Fax: 208-762-9892

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MRS. KRISTINA NICHOLAS ANDERSON
Title or Position: ADMINISTRATOR
Credential: LSW, CPRP
Phone: 208-762-9890