=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336466994
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIDLIFE CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/22/2010
-----------------------------------------------------
Last Update Date | 04/22/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1423 N GOVERNMENT WAY
-----------------------------------------------------
City | COEUR D ALENE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83814-3335
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-691-2515
-----------------------------------------------------
Fax | 208-665-2398
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 912 N BALCONY DR
-----------------------------------------------------
City | COEUR D ALENE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83814-6899
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-691-2515
-----------------------------------------------------
Fax | 208-665-2398
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLER
-----------------------------------------------------
Name | JULIE KAY BOOTHE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 208-765-5656
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | LCSW29348
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------