Healthcare Provider Details

I. General information

NPI: 1144342478
Provider Name (Legal Business Name): WANDA G. FOX
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2007
Last Update Date: 07/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

819 HWY 2 PIONEER SQ. 204
SANDPOINT ID
83864-0000
US

IV. Provider business mailing address

819 HWY 2 PIONEER SQ. 204
SANDPOINT ID
83864-0000
US

V. Phone/Fax

Practice location:
  • Phone: 208-265-0745
  • Fax: 208-255-1543
Mailing address:
  • Phone: 208-265-0745
  • Fax: 208-255-1543

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License NumberLSW-2722
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberLSW-2722
License Number StateID

VIII. Authorized Official

Name: MS. WANDA G. FOX
Title or Position: PROGRAM DIRECTOR
Credential: LSW,MSW
Phone: 208-265-0745