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General NPI Number Information
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NPI Number | 1013277128
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Entity Type | Organization
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Legal Business Name | STATE OF MIND COUNSELING AND WELLNESS CENTER
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Dates
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Enumeration Date | 05/22/2012
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Last Update Date | 07/27/2012
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Provider Practice Location Address
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Address Line | 141 N PALMETTO AVE UNIT 1626
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City | EAGLE
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State | ID
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Zip | 83616-8066
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Country | US
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Telephone | 208-939-3999
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Fax |
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Provider Business Mailing Address
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Address Line | 233 W STATE ST STE D
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City | EAGLE
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State | ID
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Zip | 83616-4982
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | LPC
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Name | LYNDA SMITH
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Credential |
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Telephone | 208-602-2293
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 4841
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number | 4841
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License Number State | ID
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Taxonomy #3
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Taxonomy Code | 261QM0855X
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Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
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License Number | 4841
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License Number State | ID
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