Healthcare Provider Details

I. General information

NPI: 1376103713
Provider Name (Legal Business Name): IDAHO ANTI-TRAFFICKING COALITION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2019
Last Update Date: 02/12/2020
Certification Date: 02/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

925 N MAIN ST
MERIDIAN ID
83642-2301
US

IV. Provider business mailing address

868 E RIVERSIDE DR STE 170
EAGLE ID
83616-6025
US

V. Phone/Fax

Practice location:
  • Phone: 208-600-2184
  • Fax:
Mailing address:
  • Phone: 208-630-6601
  • Fax: 208-506-6851

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER ZEILINSKI
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 208-630-6601