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General NPI Number Information
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NPI Number | 1053615260
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Entity Type | Organization
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Legal Business Name | STATE OF IDAHO
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Dates
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Enumeration Date | 01/03/2011
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Last Update Date | 01/03/2011
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Provider Practice Location Address
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Address Line | 700 E ALICE ST
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City | BLACKFOOT
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State | ID
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Zip | 83221-4925
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Country | US
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Telephone | 208-785-8506
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Fax | 208-785-8518
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Provider Business Mailing Address
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Address Line | 700 E ALICE ST PO BOX 400
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City | BLACKFOOT
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State | ID
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Zip | 83221-4925
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Country | US
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Telephone | 208-785-8506
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Fax | 208-785-8518
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Authorized Official
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Title or Position | PATIENT ACCOUNT SPECIALIST
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Name | LORNA B COLVIN
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Credential |
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Telephone | 208-785-8506
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 17
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License Number State | ID
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