Healthcare Provider Details

I. General information

NPI: 1164137105
Provider Name (Legal Business Name): RECOVERY ROCKS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/13/2023
Last Update Date: 05/09/2023
Certification Date: 05/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

414 N LINCOLN AVE STE 2
JEROME ID
83338-2300
US

IV. Provider business mailing address

414 N LINCOLN AVE STE 2
JEROME ID
83338-2300
US

V. Phone/Fax

Practice location:
  • Phone: 208-536-0536
  • Fax: 208-324-5597
Mailing address:
  • Phone: 208-324-5431
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: GERLYN DANETTE WALKER
Title or Position: OWNER
Credential: LPC
Phone: 208-539-0838