Healthcare Provider Details

I. General information

NPI: 1114227097
Provider Name (Legal Business Name): MOUNTAIN STATES CHEMICAL DEPENDENCY AND COUNSELING SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2010
Last Update Date: 10/26/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1305 2ND ST S SUITE 201
NAMPA ID
83651-3944
US

IV. Provider business mailing address

1305 2ND ST S SUITE 201
NAMPA ID
83651-3944
US

V. Phone/Fax

Practice location:
  • Phone: 208-466-7771
  • Fax: 208-463-0205
Mailing address:
  • Phone: 208-466-7771
  • Fax: 208-463-0205

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MAUREEN OLEARY
Title or Position: AGENCY DIRECTOR
Credential: LCSW
Phone: 208-466-7771