=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457867962
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STILLWATER CONNECTION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/19/2017
-----------------------------------------------------
Last Update Date | 03/29/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 22480 DUFF LN
-----------------------------------------------------
City | MIDDLETON
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83644-6041
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-965-4502
-----------------------------------------------------
Fax | 208-505-4280
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 22480 DUFF LN
-----------------------------------------------------
City | MIDDLETON
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83644-6041
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-965-4502
-----------------------------------------------------
Fax | 208-505-4280
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. TANYA KRISTEN NELSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 208-800-2758
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QM0855X
-----------------------------------------------------
Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | LPC6027
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------