=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346633849
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THERAPY IN MOTION INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/09/2015
-----------------------------------------------------
Last Update Date | 03/09/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 165 WEST MAIN ST
-----------------------------------------------------
City | LAVA HOT SPRINGS
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83246
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-776-5125
-----------------------------------------------------
Fax | 866-287-2315
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 404
-----------------------------------------------------
City | LAVA HOT SPRINGS
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83246-0404
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-776-5125
-----------------------------------------------------
Fax | 866-287-2315
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL DIRECTOR
-----------------------------------------------------
Name | JOHN CHARLES FLEMING
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 208-776-5125
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 324500000X
-----------------------------------------------------
Taxonomy Name | Substance Abuse Rehabilitation Facility
-----------------------------------------------------
License Number | LCSW-29011
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------