Healthcare Provider Details

I. General information

NPI: 1063918464
Provider Name (Legal Business Name): IDAHO PSYCHOLOGICAL RESOURCES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2018
Last Update Date: 08/22/2026
Certification Date: 08/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4433 BEVERLAND ROAD
MACKAY ID
83251
US

IV. Provider business mailing address

PO BOX 402
MACKAY ID
83251-0402
US

V. Phone/Fax

Practice location:
  • Phone: 208-588-5770
  • Fax: 208-588-2984
Mailing address:
  • Phone: 208-588-2770
  • Fax: 208-588-2984

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: ALEXIS SMITH
Title or Position: ADMINSTRATOR
Credential:
Phone: 208-604-5193