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General NPI Number Information
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NPI Number | 1114417029
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Entity Type | Organization
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Legal Business Name | MOUNTAIN WEST SUPPORTIVE SERVICES
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Dates
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Enumeration Date | 05/16/2018
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Last Update Date | 05/16/2018
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Provider Practice Location Address
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Address Line | 1970 E 17TH ST STE 101
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City | IDAHO FALLS
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State | ID
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Zip | 83404-8046
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Country | US
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Telephone | 208-715-0218
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Fax | 208-715-0210
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Provider Business Mailing Address
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Address Line | 1970 E 17TH ST STE 101
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City | IDAHO FALLS
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State | ID
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Zip | 83404-8046
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Country | US
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Telephone | 208-715-0218
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Fax | 208-715-0210
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Authorized Official
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Title or Position | OWNER
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Name | KALLE STEPHANIE SMITH
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Credential | LSW
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Telephone | 208-715-0218
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251B00000X
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Taxonomy Name | Case Management Agency
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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