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General NPI Number Information
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NPI Number | 1366188294
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Entity Type | Organization
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Legal Business Name | DELTERRA
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Dates
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Enumeration Date | 05/12/2022
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Last Update Date | 05/12/2022
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Provider Practice Location Address
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Address Line | 172 CHARLES PL
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City | REXBURG
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State | ID
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Zip | 83440-5452
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Country | US
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Telephone | 385-437-0188
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Fax | 855-710-7572
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Provider Business Mailing Address
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Address Line | 172 CHARLES PL
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City | REXBURG
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State | ID
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Zip | 83440-5452
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Country | US
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Telephone | 208-557-1544
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Fax | 855-710-7572
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Authorized Official
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Title or Position | OWNER/CLINICIAN
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Name | DALYNN N MOORE
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Credential | LCPC
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Telephone | 385-437-0188
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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