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General NPI Number Information
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NPI Number | 1104004928
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Entity Type | Organization
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Legal Business Name | IDAHO DEPT OF HEALTH & WELFARE AMHCALPGREG3
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Dates
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Enumeration Date | 02/04/2008
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Last Update Date | 01/28/2009
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Provider Practice Location Address
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Address Line | 3402 FRANKLIN RD
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City | CALDWELL
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State | ID
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Zip | 83605-6932
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Country | US
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Telephone | 208-459-0092
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Fax | 208-454-7714
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Provider Business Mailing Address
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Address Line | 3402 FRANKLIN RD
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City | CALDWELL
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State | ID
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Zip | 83605-6932
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Country | US
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Telephone | 208-459-0092
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Fax | 208-454-7714
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Authorized Official
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Title or Position | FIELD OPERATIONS MANAGER
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Name | TODD L HURT
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Credential | MS
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Telephone | 208-455-7057
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TP0016X
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Taxonomy Name | Prescribing (Medical) Psychologist
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License Number |
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License Number State |
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