Healthcare Provider Details

I. General information

NPI: 1720118904
Provider Name (Legal Business Name): IDAHO DEPT OF HEALTH & WELFARE AMH PSR MT HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2420 AMERICAN LEGION BLVD
MOUNTAIN HOME ID
83647-3146
US

IV. Provider business mailing address

1720 WESTGATE DR SUITE B-1
BOISE ID
83704-7164
US

V. Phone/Fax

Practice location:
  • Phone: 208-587-9061
  • Fax: 208-587-5024
Mailing address:
  • Phone: 208-334-0894
  • Fax: 208-334-0804

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: GINA WESTCOTT
Title or Position: PROGRAM MANAGER
Credential: M.A.
Phone: 208-334-0969