Healthcare Provider Details

I. General information

NPI: 1649262825
Provider Name (Legal Business Name): SUMMIT HEALTH PROFESSIONALS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2005
Last Update Date: 11/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3760 WASHINGTON PKWY
IDAHO FALLS ID
83404-7593
US

IV. Provider business mailing address

3760 WASHINGTON PKWY
IDAHO FALLS ID
83404-7593
US

V. Phone/Fax

Practice location:
  • Phone: 208-524-4953
  • Fax: 208-524-7335
Mailing address:
  • Phone: 208-524-4953
  • Fax: 208-524-7335

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLCPC-323
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLCSW-1311
License Number StateID
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberM8621
License Number StateID
# 4
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. NIKOLA ANDERSEN
Title or Position: PHYSICIAN/PARTNER
Credential:
Phone: 208-524-4953