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General NPI Number Information
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NPI Number | 1972774602
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Entity Type | Organization
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Legal Business Name | PORTO UNIAO, INC
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Dates
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Enumeration Date | 03/20/2008
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Last Update Date | 06/10/2008
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Provider Practice Location Address
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Address Line | 2180 W IRONWOOD CENTER DR
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City | COEUR D ALENE
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State | ID
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Zip | 83814-2639
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Country | US
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Telephone | 208-676-0926
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Fax | 208-772-5969
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Provider Business Mailing Address
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Address Line | 212 W IRONWOOD DR STE D311
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City | COEUR D ALENE
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State | ID
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Zip | 83814-1403
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Country | US
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Telephone | 208-676-0926
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Fax | 208-772-5969
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Authorized Official
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Title or Position | PSYCHOLOGIST
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Name | DR. LAVERL H. WILHELM
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Credential | PHD
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Telephone | 208-676-0926
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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 | 202060
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License Number State | ID
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