Healthcare Provider Details

I. General information

NPI: 1225107923
Provider Name (Legal Business Name): EMMETT FAMILY SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 09/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2007 E QUAIL RUN RD SUITE 1
EMMETT ID
83617-5059
US

IV. Provider business mailing address

2007 E QUAIL RUN RD SUITE 1
EMMETT ID
83617-5059
US

V. Phone/Fax

Practice location:
  • Phone: 208-365-5445
  • Fax: 208-365-6226
Mailing address:
  • Phone: 208-365-5445
  • Fax: 208-365-6226

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberNA
License Number StateNULL

VIII. Authorized Official

Name: MR. MICHAEL S LEE
Title or Position: CO-OWNER
Credential: LCSW
Phone: 208-365-5445