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General NPI Number Information
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NPI Number | 1063918464
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Entity Type | Organization
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Legal Business Name | IDAHO PSYCHOLOGICAL RESOURCES LLC
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Dates
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Enumeration Date | 04/04/2018
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Last Update Date | 06/21/2021
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Provider Practice Location Address
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Address Line | 4433 BEVERLAND ROAD
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City | MACKAY
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State | ID
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Zip | 83251
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Country | US
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Telephone | 208-588-5770
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Fax | 208-588-2984
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Provider Business Mailing Address
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Address Line | PO BOX 402
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City | MACKAY
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State | ID
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Zip | 83251-0402
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Country | US
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Telephone | 208-588-2770
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Fax | 208-588-2984
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Authorized Official
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Title or Position | ADMINSTRATOR
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Name | ALEXIS GAMETT
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Credential |
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Telephone | 208-604-5193
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | LPC-3661
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | LCSW-27821
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License Number State | ID
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