Healthcare Provider Details

I. General information

NPI: 1730886003
Provider Name (Legal Business Name): ECETERA THERAPY CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2023
Last Update Date: 02/15/2023
Certification Date: 02/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1070 RIVERWALK DR
IDAHO FALLS ID
83402-3341
US

IV. Provider business mailing address

175 E 18TH ST
IDAHO FALLS ID
83404-6016
US

V. Phone/Fax

Practice location:
  • Phone: 208-314-3731
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: HEIDI R MAURER
Title or Position: OWNER
Credential:
Phone: 208-709-9215