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General NPI Number Information
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NPI Number | 1174629976
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Entity Type | Organization
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Legal Business Name | PORTNEUF VALLEY FAMILY CENTER
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Dates
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Enumeration Date | 09/16/2006
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Last Update Date | 06/27/2025
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Provider Practice Location Address
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Address Line | 444 HOSPITAL WAY STE 477
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City | POCATELLO
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State | ID
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Zip | 83201-2744
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Country | US
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Telephone | 208-233-7832
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Fax | 208-233-7835
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Provider Business Mailing Address
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Address Line | 444 HOSPITAL WAY STE 477
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City | POCATELLO
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State | ID
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Zip | 83201-2744
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Country | US
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Telephone | 208-233-7832
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Fax | 208-233-7835
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Authorized Official
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Title or Position | OWNER/ADMINISTRATOR
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Name | ROBERT DE WALL
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Credential |
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Telephone | 208-233-7832
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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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 | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number |
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License Number State |
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Taxonomy #6
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #7
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number |
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License Number State |
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