Healthcare Provider Details

I. General information

NPI: 1962050989
Provider Name (Legal Business Name): BRICK HOUSE RECOVERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/03/2019
Last Update Date: 12/30/2019
Certification Date: 12/30/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 LAND BANK ST
IDAHO FALLS ID
83402-1809
US

IV. Provider business mailing address

3663 N LAKEHARBOR LN
BOISE ID
83703-6913
US

V. Phone/Fax

Practice location:
  • Phone: 801-350-1716
  • Fax:
Mailing address:
  • Phone: 801-350-1716
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JASON D COOMBS
Title or Position: CEO
Credential: MPC
Phone: 801-350-1716