Healthcare Provider Details

I. General information

NPI: 1093354318
Provider Name (Legal Business Name): COUNSELING & TREATMENT CENTER OF IDAHO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2020
Last Update Date: 10/23/2020
Certification Date: 10/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

859 S YELLOWSTONE HWY STE 302
REXBURG ID
83440-5294
US

IV. Provider business mailing address

859 S YELLOWSTONE HWY STE 302
REXBURG ID
83440-5294
US

V. Phone/Fax

Practice location:
  • Phone: 208-932-5363
  • Fax: 205-273-8403
Mailing address:
  • Phone: 208-932-5363
  • Fax: 205-273-8403

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health 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: DEBORAH FINCH
Title or Position: OFFICE MANAGER
Credential:
Phone: 801-857-9136