Healthcare Provider Details

I. General information

NPI: 1316649106
Provider Name (Legal Business Name): IDAHO COUNSELING AND TRAUMA CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2023
Last Update Date: 03/17/2023
Certification Date: 03/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1309 PONDEROSA DR
SANDPOINT ID
83864-8278
US

IV. Provider business mailing address

204 N 4TH AVE UNIT 2423
SANDPOINT ID
83864-0476
US

V. Phone/Fax

Practice location:
  • Phone: 208-278-6027
  • Fax:
Mailing address:
  • Phone: 208-278-6027
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: TAMARA K BAKER
Title or Position: OWNER
Credential: LMFT
Phone: 208-278-6027