Healthcare Provider Details

I. General information

NPI: 1295379865
Provider Name (Legal Business Name): HIGH COUNTRY BEHAVIORAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2019
Last Update Date: 11/03/2025
Certification Date: 11/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1248 E 17TH ST
IDAHO FALLS ID
83404-6147
US

IV. Provider business mailing address

PO BOX 376
AFTON WY
83110-0376
US

V. Phone/Fax

Practice location:
  • Phone: 208-542-1026
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QR0800X
TaxonomyRecovery Care Clinic/Center
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: KIPP DANA
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 307-885-9883