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General NPI Number Information
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NPI Number | 1770987844
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Entity Type | Organization
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Legal Business Name | BRICK HOUSE RECOVERY
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Dates
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Enumeration Date | 10/17/2014
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Last Update Date | 12/30/2019
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Provider Practice Location Address
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Address Line | 3663 N LAKEHARBOR LN
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City | BOISE
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State | ID
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Zip | 83703
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Country | US
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Telephone | 801-350-1716
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Fax | 208-286-4292
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Provider Business Mailing Address
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Address Line | 3663 N LAKEHARBOR LN
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City | BOISE
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State | ID
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Zip | 83703-6913
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Country | US
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Telephone | 801-350-1716
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Fax | 208-286-4292
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Authorized Official
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Title or Position | CEO
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Name | JASON D COOMBS
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Credential | MPC
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Telephone | 801-350-1716
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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 | 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 |
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License Number State | ID
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Taxonomy #3
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number |
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License Number State | ID
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Taxonomy #4
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number |
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License Number State | ID
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