Healthcare Provider Details

I. General information

NPI: 1770647612
Provider Name (Legal Business Name): EMMETT FAMILY SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2006
Last Update Date: 09/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 N 16TH ST STE 108 & 110
PAYETTE ID
83661-2781
US

IV. Provider business mailing address

501 N 16TH ST STE 108 & 110
PAYETTE ID
83661-2781
US

V. Phone/Fax

Practice location:
  • Phone: 208-642-2600
  • Fax: 208-642-6164
Mailing address:
  • Phone: 208-642-2600
  • Fax: 208-642-6164

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number26695
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number446A
License Number StateID
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number24210
License Number StateID

VIII. Authorized Official

Name: MR. MICHAEL S LEE
Title or Position: CO-OWNER
Credential: LCSW, LMHP
Phone: 208-559-7773