Healthcare Provider Details

I. General information

NPI: 1306299805
Provider Name (Legal Business Name): MAITRI COMMUNITY SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2016
Last Update Date: 07/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3709 N LOCUST GROVE RD SUITE 100
MERIDIAN ID
83646-6449
US

IV. Provider business mailing address

3709 N LOCUST GROVE RD SUITE 100
MERIDIAN ID
83646-6449
US

V. Phone/Fax

Practice location:
  • Phone: 208-957-5360
  • Fax: 208-493-4331
Mailing address:
  • Phone: 208-957-5360
  • Fax: 208-493-4331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number31259
License Number StateID

VIII. Authorized Official

Name: LORI NICOLE EATON
Title or Position: OWNER/PROVIDER
Credential: LCSW
Phone: 208-957-5360