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General NPI Number Information
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NPI Number | 1093040917
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Entity Type | Organization
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Legal Business Name | PEREGRINE CORP, PC
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Dates
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Enumeration Date | 10/09/2009
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Last Update Date | 09/25/2013
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Provider Practice Location Address
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Address Line | 37 HIGHWAY 57
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City | PRIEST RIVER
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State | ID
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Zip | 83856-6559
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Country | US
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Telephone | 208-448-4855
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Fax | 208-448-2467
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Provider Business Mailing Address
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Address Line | PO BOX 205
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City | PRIEST RIVER
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State | ID
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Zip | 83856-0205
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Country | US
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Telephone | 208-448-4855
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Fax | 208-448-2467
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Authorized Official
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Title or Position | BOARD PRESIDENT
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Name | MS. DORLEA ANN KNIZLEY
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Credential | LPC
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Telephone | 208-448-4855
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | LCPC - 139
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License Number State | ID
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