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General NPI Number Information
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NPI Number | 1972320984
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Entity Type | Organization
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Legal Business Name | OBSIDAIN MENTAL HEALTH, PLLC
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Dates
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Enumeration Date | 09/21/2024
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Last Update Date | 09/21/2024
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Provider Practice Location Address
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Address Line | 1034 MAIN ST
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City | LEWISTON
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State | ID
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Zip | 83501-1842
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Country | US
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Telephone | 706-979-1524
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Fax |
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Provider Business Mailing Address
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Address Line | 417 2ND AVE
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City | LEWISTON
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State | ID
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Zip | 83501-2111
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER/PROVIDER
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Name | MS. CHRISTINE THOMAS
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Credential | PMHNP-BC
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Telephone | 706-979-1524
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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