Healthcare Provider Details

I. General information

NPI: 1790504561
Provider Name (Legal Business Name): SERENITY TREATMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/08/2024
Last Update Date: 10/08/2024
Certification Date: 10/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1034 MAIN ST
LEWISTON ID
83501-1842
US

IV. Provider business mailing address

1034 MAIN ST
LEWISTON ID
83501-1842
US

V. Phone/Fax

Practice location:
  • Phone: 208-743-5906
  • Fax: 833-264-6643
Mailing address:
  • Phone: 208-743-5906
  • Fax: 833-264-6643

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. ELAINE B DUFFORD
Title or Position: OWNER/CLINICIAL
Credential: LCSW
Phone: 208-305-8237