Healthcare Provider Details

I. General information

NPI: 1396876850
Provider Name (Legal Business Name): IDAHO DEPT. OF HEALTH & WELFARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2007
Last Update Date: 01/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

803 HARRISON ST.
TWIN FALLS ID
83301-3925
US

IV. Provider business mailing address

803 HARRISON ST.
TWIN FALLS ID
83301-3925
US

V. Phone/Fax

Practice location:
  • Phone: 208-732-1630
  • Fax: 208-736-2135
Mailing address:
  • Phone: 208-732-1630
  • Fax: 208-736-2135

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SCOTT RASMUSSEN
Title or Position: HUMAN SERVICES FIELD PROGRAM MANAGE
Credential: LCSW
Phone: 208-732-1601