Healthcare Provider Details

I. General information

NPI: 1366827255
Provider Name (Legal Business Name): RIVERSIDE RECOVERY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2015
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1720 18TH AVE
LEWISTON ID
83501-4047
US

IV. Provider business mailing address

1720 18TH AVE
LEWISTON ID
83501-4047
US

V. Phone/Fax

Practice location:
  • Phone: 208-746-4097
  • Fax: 208-746-2294
Mailing address:
  • Phone: 208-746-4097
  • Fax: 208-746-2294

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLCPC-5714
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCPC-2714
License Number StateID

VIII. Authorized Official

Name: SARA LIGHT BENNETT
Title or Position: OWNER
Credential:
Phone: 208-746-4097