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General NPI Number Information
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NPI Number | 1205720364
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Entity Type | Organization
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Legal Business Name | OBSIDIAN COUNSELING LLC
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Dates
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Enumeration Date | 06/04/2025
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Last Update Date | 06/04/2025
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Provider Practice Location Address
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Address Line | 200 S MAIN ST STE P1
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City | POCATELLO
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State | ID
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Zip | 83204-3261
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Country | US
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Telephone | 208-244-6799
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Fax | 208-274-9407
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Provider Business Mailing Address
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Address Line | 200 S MAIN ST STE P1
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City | POCATELLO
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State | ID
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Zip | 83204-3261
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Country | US
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Telephone | 208-244-6799
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Fax | 208-274-9407
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Authorized Official
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Title or Position | OWNER
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Name | YESENIA IBARRA TREJO
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Credential | LCSW
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Telephone | 208-244-6799
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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 |
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License Number State |
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