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General NPI Number Information
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NPI Number | 1508554940
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Entity Type | Organization
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Legal Business Name | ICARE CENTER FOR CHANGE
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Dates
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Enumeration Date | 04/25/2023
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Last Update Date | 04/25/2023
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Provider Practice Location Address
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Address Line | 1689 E 4000 N
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City | BUHL
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State | ID
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Zip | 83316-5647
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Country | US
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Telephone | 208-918-2473
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Fax |
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Provider Business Mailing Address
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Address Line | 1689 E 4000 N
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City | BUHL
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State | ID
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Zip | 83316-5647
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Country | US
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Telephone | 208-918-2473
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Fax |
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Authorized Official
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Title or Position | OWNER, CLINICIAN
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Name | KELLY GRAFF
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Credential | APRN-CNS
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Telephone | 208-918-2473
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Psychologist
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License Number |
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License Number State |
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