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General NPI Number Information
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NPI Number | 1811451438
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Entity Type | Organization
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Legal Business Name | IDAHO INSTITUTE OF GENDER AND SEX THERAPY
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Dates
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Enumeration Date | 01/28/2019
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Last Update Date | 12/10/2021
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Provider Practice Location Address
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Address Line | 6003 W OVERLAND RD STE 105
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City | BOISE
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State | ID
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Zip | 83709-3075
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Country | US
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Telephone | 208-417-8428
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Fax | 208-216-1434
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Provider Business Mailing Address
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Address Line | 3278 E RENWICK ST
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City | MERIDIAN
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State | ID
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Zip | 83642-6467
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Country | US
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Telephone | 208-417-8428
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Fax | 208-216-1434
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Authorized Official
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Title or Position | OWNER
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Name | MR. JEREMY WAYNE IRVIN
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Credential | LCSW, M.ED., CST
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Telephone | 208-417-8428
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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