=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083326219
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADVANCED MENTAL HEALTH AND NEUROFEEDBACK
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/19/2022
-----------------------------------------------------
Last Update Date | 12/19/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2001 S WOODRUFF AVE STE 11
-----------------------------------------------------
City | IDAHO FALLS
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83404-6372
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-705-6771
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 631 MARK AVE
-----------------------------------------------------
City | IDAHO FALLS
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83401-3116
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-705-6771
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | MRS. CONNIE HOBBS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 208-705-6771
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------