Healthcare Provider Details

I. General information

NPI: 1316284490
Provider Name (Legal Business Name): IDAHO BEHAVIORAL HEALTH, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2013
Last Update Date: 01/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 S JOHNS AVE
EMMETT ID
83617-3030
US

IV. Provider business mailing address

2273 S VISTA AVE #190
BOISE ID
83705-7341
US

V. Phone/Fax

Practice location:
  • Phone: 208-343-2737
  • Fax: 208-342-3238
Mailing address:
  • Phone: 208-343-2737
  • Fax: 208-342-3238

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberM-4112
License Number StateID

VIII. Authorized Official

Name: TAMI JONES
Title or Position: PRESIDENT AND CEO
Credential: LCSW
Phone: 208-343-2737