MEDICARE: CLEARWATER COUNSELING

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0850X	Adult Mental Health Clinic/Center	LCSW1120	ID
2	261QM0850X	Adult Mental Health Clinic/Center	LCPC4218	ID

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1134361207
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLEARWATER COUNSELING

Provider Business Mailing Address
First Line	:	1020 MAIN ST
Second Line	:	PO BOX 1123
City	:	LEWISTON
State	:	ID
Zip	:	83501-1842
Country	:	US
Telephone Number	:	208-743-8101
Fax Number	:	208-746-7402

Provider Business Practice Location Address
First Line	:	318 1/2 E MAIN ST
Second Line	:
City	:	GRANGEVILLE
State	:	ID
Zip	:	83530-2238
Country	:	US
Telephone Number	:	208-983-7717
Fax Number	:	208-983-7787

Authorized Official
Title or Position	:	OWNER
Name	:	MR. MARK ROBERT JONES
Credential	:	LCSW
Telephone Number	:	208-743-8101

Provider Enumeration Date	:	04/03/2009
Last Update Date	:	04/03/2009

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Directions to “CLEARWATER COUNSELING ” Practice Location

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