=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437554383
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AMARIS DEVELOPMENT GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/04/2014
-----------------------------------------------------
Last Update Date | 11/04/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13559 W PRAIRIE AVE
-----------------------------------------------------
City | POST FALLS
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83854-5935
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-245-5179
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13559 W PRAIRIE AVE
-----------------------------------------------------
City | POST FALLS
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83854-5935
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-245-5179
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRINCIPAL
-----------------------------------------------------
Name | ELIZABETH GALENE PATZER
-----------------------------------------------------
Credential | LCSW, MPA
-----------------------------------------------------
Telephone | 208-245-5179
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | LCSW-31159
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------