=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598578569
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE ROCK BEHAVIORAL HEALTH
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/31/2025
-----------------------------------------------------
Last Update Date | 03/19/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2114 VILLAGE PARK AVE STE 200
-----------------------------------------------------
City | TWIN FALLS
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83301-4172
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-441-0767
-----------------------------------------------------
Fax | 208-441-0367
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2114 VILLAGE PARK AVE STE 200
-----------------------------------------------------
City | TWIN FALLS
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83301-4172
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-441-0767
-----------------------------------------------------
Fax | 208-441-0367
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BUSINESS OWNER, PROVIDER
-----------------------------------------------------
Name | MICHELLE HARCOURT
-----------------------------------------------------
Credential | DNP, FNP-BC
-----------------------------------------------------
Telephone | 208-220-3886
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------