Healthcare Provider Details

I. General information

NPI: 1437066826
Provider Name (Legal Business Name): OAK TREE SUPPORTED LIVING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2026
Last Update Date: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

522 W RIVERSIDE AVE
SPOKANE WA
99201-0580
US

IV. Provider business mailing address

1390 E ELDERBERRY CIR
COEUR D ALENE ID
83815-6559
US

V. Phone/Fax

Practice location:
  • Phone: 208-620-1477
  • Fax:
Mailing address:
  • Phone: 208-620-1477
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: HEIDI PROVENCE
Title or Position: OWNER/ADMINISTRATOR
Credential:
Phone: 208-620-1477