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General NPI Number Information
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NPI Number | 1023667524
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Entity Type | Organization
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Legal Business Name | GEM STATE DEVELOPMENTAL CENTER LLC
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Dates
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Enumeration Date | 09/06/2019
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Last Update Date | 09/06/2019
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Provider Practice Location Address
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Address Line | 818 NW 15TH ST
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City | MERIDIAN
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State | ID
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Zip | 83642-3724
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Country | US
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Telephone | 208-888-5566
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Fax | 208-888-5578
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Provider Business Mailing Address
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Address Line | 818 NW 15TH ST
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City | MERIDIAN
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State | ID
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Zip | 83642-3724
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Country | US
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Telephone | 208-888-5566
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Fax | 208-888-5578
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Authorized Official
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Title or Position | CLINICAL DIRECTOR
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Name | MS. LORI JO POOLE
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Credential | LCSW
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Telephone | 208-888-5566
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 373H00000X
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Taxonomy Name | Day Training/Habilitation Specialist
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License Number |
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License Number State |
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