Healthcare Provider Details

I. General information

NPI: 1013277128
Provider Name (Legal Business Name): STATE OF MIND COUNSELING AND WELLNESS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2012
Last Update Date: 07/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

141 N PALMETTO AVE UNIT 1626
EAGLE ID
83616-8066
US

IV. Provider business mailing address

233 W STATE ST STE D
EAGLE ID
83616-4982
US

V. Phone/Fax

Practice location:
  • Phone: 208-939-3999
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number4841
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number4841
License Number StateID
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number4841
License Number StateID

VIII. Authorized Official

Name: LYNDA SMITH
Title or Position: LPC
Credential:
Phone: 208-602-2293