Healthcare Provider Details

I. General information

NPI: 1497565832
Provider Name (Legal Business Name): SNAKE RIVER MENTAL HEALTH, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2025
Last Update Date: 04/14/2025
Certification Date: 04/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15821 ALLENDALE RD
WILDER ID
83676-5864
US

IV. Provider business mailing address

15821 ALLENDALE RD
WILDER ID
83676-5864
US

V. Phone/Fax

Practice location:
  • Phone: 208-278-2863
  • Fax: 208-621-3128
Mailing address:
  • Phone: 208-278-2863
  • Fax: 208-621-3128

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: GORDON BRADLEY GREAVES
Title or Position: OWNER
Credential: PA
Phone: 801-664-1757