Healthcare Provider Details

I. General information

NPI: 1740835834
Provider Name (Legal Business Name): CRT CHILDREN SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2019
Last Update Date: 09/15/2021
Certification Date: 09/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 RODEO DR STE 510
MOSCOW ID
83843-9795
US

IV. Provider business mailing address

PO BOX 3491
MOSCOW ID
83843-1912
US

V. Phone/Fax

Practice location:
  • Phone: 208-874-8002
  • Fax: 208-596-4010
Mailing address:
  • Phone: 208-340-2370
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name: CALVIN ROGER STOWE
Title or Position: ADMINISTRATOR
Credential:
Phone: 208-340-2370