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General NPI Number Information
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NPI Number | 1083831556
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Entity Type | Organization
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Legal Business Name | EASTPORT PSR, L.L.P.
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Dates
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Enumeration Date | 04/19/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 7222 MAIN STREET
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City | BONNERS FERRY
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State | ID
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Zip | 83805
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Country | US
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Telephone | 208-946-3604
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Fax | 208-267-1681
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Provider Business Mailing Address
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Address Line | PO BOX 1093
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City | BONNERS FERRY
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State | ID
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Zip | 83805-1093
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Country | US
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Telephone | 208-946-3604
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Fax | 208-267-1681
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Authorized Official
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Title or Position | PSYCHOSOCIAL REHABILITATION SPECIAL
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Name | MS. ANNA LEE HARRIS
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Credential | BA
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Telephone | 12082677290
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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