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General NPI Number Information
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NPI Number | 1720245889
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Entity Type | Organization
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Legal Business Name | POWDER BASIN ASSOCIATES
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Dates
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Enumeration Date | 05/16/2008
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Last Update Date | 05/16/2008
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Provider Practice Location Address
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Address Line | 204 OREGON ST
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City | KELLOGG
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State | ID
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Zip | 83837-5008
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Country | US
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Telephone | 208-783-0427
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Fax | 208-783-1387
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Provider Business Mailing Address
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Address Line | 7905 N MEADOWLARK WAY SUITE E
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City | COEUR D ALENE
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State | ID
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Zip | 83815-5041
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Country | US
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Telephone | 208-209-0535
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Fax | 208-209-0966
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Authorized Official
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Title or Position | OWNER/PRESIDENT
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Name | LYNN A MOORE
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Credential | CPC
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Telephone | 208-209-0535
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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