Healthcare Provider Details

I. General information

NPI: 1235401522
Provider Name (Legal Business Name): SNAKE RIVER COUNSELING CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2012
Last Update Date: 02/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2635 CHANNING WAY SUITE B
IDAHO FALLS ID
83404-7518
US

IV. Provider business mailing address

2635 CHANNING WAY SUITE B
IDAHO FALLS ID
83404-7518
US

V. Phone/Fax

Practice location:
  • Phone: 208-552-0490
  • Fax: 208-552-2518
Mailing address:
  • Phone: 208-552-0490
  • Fax: 208-552-2518

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JULI POPEJOY
Title or Position: BILLING MANAGER
Credential:
Phone: 208-525-2090