Healthcare Provider Details

I. General information

NPI: 1326894890
Provider Name (Legal Business Name): MBKNOWLES BEHAVIOR & MENTAL HEALTH THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2024
Last Update Date: 04/25/2024
Certification Date: 04/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1170 E 800 N
SHELLEY ID
83274-5356
US

IV. Provider business mailing address

1170 E 800 N
SHELLEY ID
83274-5356
US

V. Phone/Fax

Practice location:
  • Phone: 772-284-1873
  • Fax:
Mailing address:
  • Phone: 772-284-1873
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code102L00000X
TaxonomyPsychoanalyst
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: MADISON KNOWLES
Title or Position: LICENSED COUNSELOR
Credential: LCPC
Phone: 732-606-6984