Healthcare Provider Details

I. General information

NPI: 1528136793
Provider Name (Legal Business Name): PSYCHIATRIC SERVICES, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

493 EASTLAND DR
TWIN FALLS ID
83301-7480
US

IV. Provider business mailing address

PO BOX 47
TWIN FALLS ID
83303-0047
US

V. Phone/Fax

Practice location:
  • Phone: 208-732-0995
  • Fax: 208-732-0993
Mailing address:
  • Phone: 208-732-0995
  • Fax: 208-732-0993

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberM5371
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberLMFT-2687
License Number StateID
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberLPC3381
License Number StateID
# 4
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberPA499
License Number StateID
# 5
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberLCPC3433
License Number StateID
# 6
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberCNS12
License Number StateID
# 7
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberLCPC3404
License Number StateID

VIII. Authorized Official

Name: MRS. JULIE JOHANSEN
Title or Position: ADMINISTRATOR
Credential:
Phone: 208-732-0995