=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295198240
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DAVE LIDDLE & ASSOCIATES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/29/2016
-----------------------------------------------------
Last Update Date | 03/29/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 600 N CURTIS RD SUITE 201
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83706-1449
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-424-3189
-----------------------------------------------------
Fax | 208-424-0133
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 600 N CURTIS RD SUITE 201
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83706-1449
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-424-3189
-----------------------------------------------------
Fax | 208-424-0133
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MS. AMY COLLEEN SALISBURY
-----------------------------------------------------
Credential | CADC
-----------------------------------------------------
Telephone | 208-424-3189
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------