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General NPI Number Information
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NPI Number | 1740463132
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Entity Type | Organization
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Legal Business Name | IDAHO CENTER FOR AUTISM, LLC
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Dates
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Enumeration Date | 12/10/2007
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Last Update Date | 12/10/2007
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Provider Practice Location Address
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Address Line | 5353 FRANKLIN RD
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City | BOISE
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State | ID
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Zip | 83705-1112
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Country | US
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Telephone | 208-342-0374
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 706
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City | MERIDIAN
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State | ID
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Zip | 83680-0706
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Country | US
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Telephone | 208-342-0374
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Fax |
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MS. STEPHANIE M WHIPPS
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Credential | M.S., M.ED.
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Telephone | 208-342-0374
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251B00000X
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Taxonomy Name | Case Management Agency
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License Number | 8078750
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License Number State | ID
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