=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720586969
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTH END PSYCHIATRY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/23/2018
-----------------------------------------------------
Last Update Date | 01/23/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1423 W FRANKLIN ST
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83702-5024
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-345-2212
-----------------------------------------------------
Fax | 208-345-2282
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1423 W FRANKLIN ST
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83702-5024
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-345-2212
-----------------------------------------------------
Fax | 208-345-2282
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | RICHARD A MONTGOMERY
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 208-345-2212
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------