Healthcare Provider Details

I. General information

NPI: 1639088552
Provider Name (Legal Business Name): MR. BRION PRINCE BETHEL SR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2026
Last Update Date: 09/04/2026
Certification Date: 09/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

690 N 2ND E STE 103
MOUNTAIN HOME ID
83647-1339
US

IV. Provider business mailing address

2230 N 5TH E
MOUNTAIN HOME ID
83647-1764
US

V. Phone/Fax

Practice location:
  • Phone: 208-869-2744
  • Fax:
Mailing address:
  • Phone: 208-869-2744
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: