Healthcare Provider Details

I. General information

NPI: 1083326219
Provider Name (Legal Business Name): ADVANCED MENTAL HEALTH AND NEUROFEEDBACK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2022
Last Update Date: 12/19/2022
Certification Date: 12/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 S WOODRUFF AVE STE 11
IDAHO FALLS ID
83404-6372
US

IV. Provider business mailing address

631 MARK AVE
IDAHO FALLS ID
83401-3116
US

V. Phone/Fax

Practice location:
  • Phone: 208-705-6771
  • Fax:
Mailing address:
  • Phone: 208-705-6771
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name: MRS. CONNIE HOBBS
Title or Position: MEMBER
Credential:
Phone: 208-705-6771