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General NPI Number Information
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NPI Number | 1548001522
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Entity Type | Organization
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Legal Business Name | MOUNTAIN LAUREL THERAPY LLC
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Dates
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Enumeration Date | 06/04/2024
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Last Update Date | 06/04/2024
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Provider Practice Location Address
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Address Line | 133 MAIN AVE W SUITE 300
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City | TWIN FALLS
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State | ID
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Zip | 83301
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Country | US
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Telephone | 910-308-6764
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Fax |
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Provider Business Mailing Address
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Address Line | 1011 BELL LN
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City | KIMBERLY
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State | ID
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Zip | 83341-5182
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Country | US
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Telephone | 910-308-6764
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Fax |
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Authorized Official
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Title or Position | MENTAL HEALTH THERAPIST
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Name | AMANDA LYNN OVERACRE
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Credential |
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Telephone | 910-308-6764
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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