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General NPI Number Information
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NPI Number | 1083152144
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Entity Type | Organization
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Legal Business Name | RATHDRUM COUNSELING CENTER, LLC
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Dates
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Enumeration Date | 02/08/2017
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Last Update Date | 02/08/2017
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Provider Practice Location Address
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Address Line | 14954 N COEUR DALENE ST
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City | RATHDRUM
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State | ID
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Zip | 83858-6484
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Country | US
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Telephone | 208-687-0538
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Fax | 208-687-3185
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Provider Business Mailing Address
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Address Line | 14954 N COEUR DALENE ST
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City | RATHDRUM
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State | ID
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Zip | 83858-6484
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Country | US
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Telephone | 208-687-0538
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Fax | 208-687-3185
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Authorized Official
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Title or Position | OWNER/DIRECTOR
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Name | LYNN M RUSSELL
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Credential | LCSW
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Telephone | 208-687-0538
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | LCSW 36280
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License Number State | ID
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