Healthcare Provider Details

I. General information

NPI: 1427437383
Provider Name (Legal Business Name): BANNOCK COUNTY FAMILY TREATMENT CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2015
Last Update Date: 05/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

141 N 6TH AVE
POCATELLO ID
83201-6209
US

IV. Provider business mailing address

141 N 6TH AVE
POCATELLO ID
83201-6209
US

V. Phone/Fax

Practice location:
  • Phone: 208-236-7089
  • Fax: 208-236-7097
Mailing address:
  • Phone: 208-236-7089
  • Fax: 208-236-7097

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

VIII. Authorized Official

Name: MRS. KIMBERLY JO ANDREW
Title or Position: CLINICAL DIRECTOR
Credential: LCPC
Phone: 208-236-7089