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General NPI Number Information
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NPI Number | 1306299805
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Entity Type | Organization
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Legal Business Name | MAITRI COMMUNITY SERVICES
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Dates
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Enumeration Date | 07/20/2016
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Last Update Date | 07/20/2016
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Provider Practice Location Address
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Address Line | 3709 N LOCUST GROVE RD SUITE 100
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City | MERIDIAN
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State | ID
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Zip | 83646-6449
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Country | US
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Telephone | 208-957-5360
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Fax | 208-493-4331
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Provider Business Mailing Address
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Address Line | 3709 N LOCUST GROVE RD SUITE 100
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City | MERIDIAN
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State | ID
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Zip | 83646-6449
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Country | US
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Telephone | 208-957-5360
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Fax | 208-493-4331
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Authorized Official
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Title or Position | OWNER/PROVIDER
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Name | LORI NICOLE EATON
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Credential | LCSW
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Telephone | 208-957-5360
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 31259
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License Number State | ID
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