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General NPI Number Information
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NPI Number | 1376670091
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Entity Type | Organization
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Legal Business Name | IDAHO DEPT OF HEALTH & WELFARE REG 1 AMH PSR BONNERS FERRY
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Dates
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Enumeration Date | 02/28/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | RT 4 6522 TAMARACK LN
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City | BONNERS FERRY
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State | ID
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Zip | 83805-9805
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Country | US
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Telephone | 208-267-3187
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Fax | 208-267-3251
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Provider Business Mailing Address
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Address Line | RT 4 6522 TAMARACK LN
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City | BONNERS FERRY
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State | ID
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Zip | 83805-9805
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Country | US
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Telephone | 208-267-3187
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Fax | 208-267-3251
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Authorized Official
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Title or Position | PROGRAM MANAGER
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Name | CORA JO GUSSENHOVEN
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Credential |
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Telephone | 208-769-1406
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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