Healthcare Provider Details

I. General information

NPI: 1396385845
Provider Name (Legal Business Name): ALPINE INTEGRATED WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/13/2020
Last Update Date: 04/21/2026
Certification Date: 04/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 RIVER ST E SUITE D
KETCHUM ID
83340
US

IV. Provider business mailing address

PO BOX 533
KETCHUM ID
83340-0481
US

V. Phone/Fax

Practice location:
  • Phone: 503-936-0379
  • Fax: 413-677-2481
Mailing address:
  • Phone: 503-936-0379
  • Fax: 413-677-2481

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MR. DANIEL JACOB ROTHMAN
Title or Position: EXECUTIVE DIRECTOR
Credential: MA, LCPC
Phone: 503-936-0379