Healthcare Provider Details

I. General information

NPI: 1104011337
Provider Name (Legal Business Name): ALLIED MENTAL HEALTH SERVICES, P.L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2007
Last Update Date: 09/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11104 W. STATE ST.
STAR ID
83669
US

IV. Provider business mailing address

PO BOX 545
STAR ID
83669-0545
US

V. Phone/Fax

Practice location:
  • Phone: 208-286-7967
  • Fax: 208-286-9047
Mailing address:
  • Phone: 208-286-7967
  • Fax: 208-286-9047

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. CORY L. THACKER
Title or Position: PRESIDENT/OWNER
Credential: M.S.
Phone: 208-286-7967