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General NPI Number Information
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NPI Number | 1679860746
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Entity Type | Organization
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Legal Business Name | SYRINGA PSYCHOTHERAPY
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Dates
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Enumeration Date | 07/08/2011
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Last Update Date | 07/08/2011
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Provider Practice Location Address
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Address Line | 212 N 1ST AVE SUITE 203
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City | SANDPOINT
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State | ID
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Zip | 83864-1436
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Country | US
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Telephone | 208-946-5242
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Fax |
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Provider Business Mailing Address
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Address Line | 212 N 1ST AVE SUITE 203
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City | SANDPOINT
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State | ID
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Zip | 83864-1436
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Country | US
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Telephone | 208-946-5242
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Fax |
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Authorized Official
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Title or Position | PARTNER
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Name | MR. CLARK EDWARD RICHMAN
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Credential | LCPC
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Telephone | 208-946-5242
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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 | LPC-4235
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | LCPC-4465
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License Number State | ID
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