Healthcare Provider Details

I. General information

NPI: 1427977453
Provider Name (Legal Business Name): TINA CRAIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2026
Last Update Date: 07/13/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1820 E 17TH ST STE 190
IDAHO FALLS ID
83404-6518
US

IV. Provider business mailing address

1820 E 17TH ST STE 190
IDAHO FALLS ID
83404-6518
US

V. Phone/Fax

Practice location:
  • Phone: 208-419-6102
  • Fax: 208-549-9618
Mailing address:
  • Phone: 208-419-6102
  • Fax: 208-549-9618

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: