Healthcare Provider Details

I. General information

NPI: 1063574226
Provider Name (Legal Business Name): CREEKSIDE COUNSELING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 10/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 W SUNNYSIDE RD STE 1
IDAHO FALLS ID
83402-4619
US

IV. Provider business mailing address

550 W SUNNYSIDE RD STE 1
IDAHO FALLS ID
83402-4619
US

V. Phone/Fax

Practice location:
  • Phone: 208-529-5777
  • Fax: 208-529-5778
Mailing address:
  • Phone: 208-529-5777
  • Fax: 208-529-5778

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberNP1094A
License Number StateID

VIII. Authorized Official

Name: JANET O. ALLEN
Title or Position: CLINICAL DIRECTOR
Credential: ED.D, LCPC
Phone: 208-529-5777