Healthcare Provider Details

I. General information

NPI: 1366986408
Provider Name (Legal Business Name): UPPER VALLEY RESOURCE & COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2016
Last Update Date: 01/03/2020
Certification Date: 01/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1223 S RAILROAD AVE
SUGAR CITY ID
83448-5072
US

IV. Provider business mailing address

PO BOX 4789
POCATELLO ID
83205-4789
US

V. Phone/Fax

Practice location:
  • Phone: 208-359-2493
  • Fax:
Mailing address:
  • Phone: 208-233-2025
  • Fax: 208-269-1226

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: DARRIN ROBERTSON
Title or Position: OWNER
Credential: NP
Phone: 208-233-2025