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General NPI Number Information
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NPI Number | 1861215295
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Entity Type | Organization
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Legal Business Name | SNAKE RIVER FAMILY SERVICES
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Dates
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Enumeration Date | 11/04/2024
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Last Update Date | 11/04/2024
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Provider Practice Location Address
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Address Line | 495 N SHILLING AVE
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City | BLACKFOOT
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State | ID
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Zip | 83221-2336
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Country | US
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Telephone | 435-744-3535
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Fax |
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Provider Business Mailing Address
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Address Line | 495 N SHILLING AVE
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City | BLACKFOOT
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State | ID
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Zip | 83221-2336
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Country | US
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Telephone | 435-744-3535
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Fax |
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Authorized Official
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Title or Position | COUNSELOR/OWNER
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Name | DALLIN BEARD
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Credential | LPC
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Telephone | 435-744-3535
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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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 |
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Taxonomy #2
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Taxonomy Code | 261QM0855X
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Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
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License Number |
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License Number State |
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