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General NPI Number Information
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NPI Number | 1720118904
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Entity Type | Organization
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Legal Business Name | IDAHO DEPT OF HEALTH & WELFARE AMH PSR MT HOME
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Dates
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Enumeration Date | 03/06/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 2420 AMERICAN LEGION BLVD
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City | MOUNTAIN HOME
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State | ID
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Zip | 83647-3146
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Country | US
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Telephone | 208-587-9061
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Fax | 208-587-5024
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Provider Business Mailing Address
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Address Line | 1720 WESTGATE DR SUITE B-1
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City | BOISE
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State | ID
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Zip | 83704-7164
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Country | US
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Telephone | 208-334-0894
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Fax | 208-334-0804
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Authorized Official
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Title or Position | PROGRAM MANAGER
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Name | GINA WESTCOTT
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Credential | M.A.
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Telephone | 208-334-0969
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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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