Healthcare Provider Details

I. General information

NPI: 1285029496
Provider Name (Legal Business Name): NEW HORIZONS MENTAL WELLNESS CLINICS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2015
Last Update Date: 04/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1352 E CENTER ST SUITE A
POCATELLO ID
83201-4734
US

IV. Provider business mailing address

1352 E CENTER ST SUITE A
POCATELLO ID
83201-4734
US

V. Phone/Fax

Practice location:
  • Phone: 208-233-2025
  • Fax: 208-233-2178
Mailing address:
  • Phone: 208-233-2025
  • Fax: 208-233-2178

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License NumberNP1034A
License Number StateID

VIII. Authorized Official

Name: DARRIN ROBERTSON
Title or Position: OWNER
Credential: PMHNP-BC
Phone: 208-233-2025