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General NPI Number Information
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NPI Number | 1538414362
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Entity Type | Organization
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Legal Business Name | GYST COUNSELING & WELLNESS LLC
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Dates
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Enumeration Date | 07/18/2012
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Last Update Date | 07/18/2012
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Provider Practice Location Address
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Address Line | 1002 BLAINE ST SUITE 208
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City | CALDWELL
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State | ID
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Zip | 83605-5574
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Country | US
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Telephone | 208-901-9159
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Fax |
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Provider Business Mailing Address
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Address Line | 11920 WEBSTER ST
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City | CALDWELL
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State | ID
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Zip | 83605-5506
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Country | US
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Telephone | 208-473-1263
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Fax |
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Authorized Official
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Title or Position | MEMBER
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Name | MR. MARK EDWARD WHITNEY
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Credential | LCSW
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Telephone | 208-473-1263
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | W112925
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License Number State | ID
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