Healthcare Provider Details

I. General information

NPI: 1245665470
Provider Name (Legal Business Name): BANNOCK YOUTH FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2013
Last Update Date: 09/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 SOUTH 19TH
POCATELLO ID
83201
US

IV. Provider business mailing address

P.O. BOX 246
POCATELLO ID
83204
US

V. Phone/Fax

Practice location:
  • Phone: 208-234-4722
  • Fax: 208-234-2135
Mailing address:
  • Phone: 208-234-4722
  • Fax: 208-234-2135

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: MS. CINDY K HANSEN
Title or Position: CLINICAL DIRECTOR
Credential: M.A.
Phone: 208-234-4722