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1548145162 NPI number — ID BEHAVIORAL HEALTH, PLLC

NPI Number: 1548145162
Health Care Provider/Practitioner: ID BEHAVIORAL HEALTH, PLLC

Information about “1548145162” NPI (ID BEHAVIORAL HEALTH, PLLC) exists in 1548145162 in HTML format HTML  |  1548145162 in plain Text format TXT  |  1548145162 in PDF (Portable Document Format) PDF  |  1548145162 in an XML format XML  formats.

NPI Number : 1548145162 – JSON Data Format

                
{
  "Npi": {
    "NPI": "1548145162",
    "EntityType": "Organization",
    "ReplacementNPI": null,
    "EIN": null,
    "IsSoleProprietor": null,
    "IsOrgSubpart": "N",
    "ParentOrgLBN": null,
    "ParentOrgTIN": null,
    "OrgName": "ID BEHAVIORAL HEALTH, PLLC",
    "LastName": null,
    "FirstName": null,
    "MiddleName": null,
    "NamePrefix": null,
    "NameSuffix": null,
    "Credential": null,
    "OtherOrgName": null,
    "OtherOrgNameTypeCode": null,
    "OtherLastName": null,
    "OtherFirstName": null,
    "OtherMiddleName": null,
    "OtherNamePrefix": null,
    "OtherNameSuffix": null,
    "OtherCredential": null,
    "OtherLastNameTypeCode": null,
    "FirstLineMailingAddress": "150 N WOODRUFF AVE",
    "SecondLineMailingAddress": null,
    "MailingAddressCityName": "IDAHO FALLS",
    "MailingAddressStateName": "ID",
    "MailingAddressPostalCode": "83401-4335",
    "MailingAddressCountryCode": "US",
    "MailingAddressTelephoneNumber": "208-557-3255",
    "MailingAddressFaxNumber": "208-471-5069",
    "FirstLinePracticeLocationAddress": "150 N WOODRUFF AVE",
    "SecondLinePracticeLocationAddress": null,
    "PracticeLocationAddressCityName": "IDAHO FALLS",
    "PracticeLocationAddressStateName": "ID",
    "PracticeLocationAddressPostalCode": "83401-4335",
    "PracticeLocationAddressCountryCode": "US",
    "PracticeLocationAddressTelephoneNumber": "208-557-3255",
    "PracticeLocationAddressFaxNumber": "208-471-5069",
    "EnumerationDate": "08/11/2025",
    "LastUpdateDate": "02/03/2026",
    "NPIDeactivationReasonCode": null,
    "NPIDeactivationReason": null,
    "NPIDeactivationDate": null,
    "NPIReactivationDate": null,
    "GenderCode": null,
    "Gender": null,
    "AuthorizedOfficialLastName": "POND",
    "AuthorizedOfficialFirstName": "TYLER",
    "AuthorizedOfficialMiddleName": "JORDAN",
    "AuthorizedOfficialTitle": "OWNER/CLINICIAN",
    "AuthorizedOfficialNamePrefix": null,
    "AuthorizedOfficialNameSuffix": null,
    "AuthorizedOfficialCredential": "PA-C",
    "AuthorizedOfficialTelephoneNumber": "208-557-3255",
    "Taxonomies": {
      "Taxonomy": {
        "TaxonomyCode": "363A00000X",
        "TaxonomyName": "Physician Assistant",
        "LicenseNumber": null,
        "LicenseNumberStateCode": null,
        "PrimaryTaxonomySwitch": "Y"
      }
    },
    "HealthcareProviderTaxonomyGroups": {
      "HealthcareProviderTaxonomyGroup": {
        "HealthcareProviderTaxonomyGroupName": "193400000X SINGLE SPECIALTY  GROUP",
        "HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
      }
    }
  }
}
                
            

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