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General NPI Number Information
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NPI Number | 1821344367
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Entity Type | Organization
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Legal Business Name | STATE AVENUE OFFICES
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Dates
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Enumeration Date | 08/02/2012
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Last Update Date | 10/09/2012
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Provider Practice Location Address
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Address Line | 39 E STATE AVE
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City | MERIDIAN
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State | ID
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Zip | 83642-2342
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Country | US
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Telephone | 208-994-3599
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Fax | 208-473-2206
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Provider Business Mailing Address
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Address Line | 39 E STATE AVE
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City | MERIDIAN
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State | ID
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Zip | 83642-2342
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Country | US
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Telephone | 208-994-3599
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Fax | 208-473-2206
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Authorized Official
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Title or Position | OWNER
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Name | CAMILLA J CAFFERTY
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Credential | LCPC
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Telephone | 208-994-3599
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number |
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License Number State |
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