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General NPI Number Information
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NPI Number | 1649808767
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Entity Type | Organization
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Legal Business Name | PSYCHOLOGICAL PREVENTATIVE HEALTH PLLC
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Dates
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Enumeration Date | 04/01/2020
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Last Update Date | 02/21/2022
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Provider Practice Location Address
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Address Line | 2300 N YELLOWSTONE HWY STE 207
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City | IDAHO FALLS
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State | ID
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Zip | 83401-1652
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Country | US
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Telephone | 801-719-7737
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Fax | 888-887-9784
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Provider Business Mailing Address
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Address Line | 2184 CHANNING WAY # 157
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City | IDAHO FALLS
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State | ID
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Zip | 83404-8034
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Country | US
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Telephone | 208-709-3925
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Fax | 888-887-9784
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Authorized Official
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Title or Position | OWNER
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Name | MELANIE RICHARSON
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Credential | LCSW
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Telephone | 801-719-7737
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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