Healthcare Provider Details

I. General information

NPI: 1437783529
Provider Name (Legal Business Name): TELEMENTAL HEALTH LINK LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2020
Last Update Date: 02/07/2024
Certification Date: 02/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4055 E BLUEBERRY ST
MERIDIAN ID
83642-8261
US

IV. Provider business mailing address

4055 E BLUEBERRY ST
MERIDIAN ID
83642-8261
US

V. Phone/Fax

Practice location:
  • Phone: 208-775-7418
  • Fax: 208-647-5008
Mailing address:
  • Phone: 208-600-2060
  • Fax: 208-647-5008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: SUSAN M DERIVAS
Title or Position: AO
Credential: PMHNP-BC
Phone: 208-775-7418