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General NPI Number Information
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NPI Number | 1902398548
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Entity Type | Organization
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Legal Business Name | PLAY THERAPY HOUSE, INC.
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Dates
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Enumeration Date | 05/30/2018
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Last Update Date | 05/30/2018
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Provider Practice Location Address
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Address Line | 3829 W CATALINA RD
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City | BOISE
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State | ID
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Zip | 83705-4611
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Country | US
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Telephone | 208-407-3562
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 5791
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City | BOISE
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State | ID
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Zip | 83705-0791
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Country | US
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Telephone | 208-407-1180
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Fax |
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Authorized Official
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Title or Position | REGISTERED AGENT
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Name | KAILEE MCMAHON
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Credential | LCPC
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Telephone | 208-407-1180
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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 | LCPC-6860
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License Number State | ID
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