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General NPI Number Information
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NPI Number | 1144396649
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Entity Type | Organization
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Legal Business Name | NORTH IDAHO TREATMENT ASSOCIATES
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Dates
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Enumeration Date | 11/27/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 302 N 5TH ST
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City | COEUR D ALENE
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State | ID
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Zip | 83814-2814
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Country | US
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Telephone | 208-664-3282
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Fax |
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Provider Business Mailing Address
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Address Line | 302 N 5TH ST
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City | COEUR D ALENE
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State | ID
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Zip | 83814-2814
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Country | US
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Telephone | 208-664-3282
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Fax |
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Authorized Official
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Title or Position | OWNER PRESIDENT
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Name | MR. THOMAS JOHN HEARN
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Credential | MSW
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Telephone | 208-664-3282
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | LCSW 403
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License Number State | ID
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