MEDICARE: IDAHO BEHAVIORAL HEALTH, INC.

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	207Q00000X	Family Medicine Physician	M-4112	ID

General Provider Information

NPI Number	:	1316284490
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IDAHO BEHAVIORAL HEALTH, INC.

Provider Business Mailing Address
First Line	:	2273 S VISTA AVE
Second Line	:	#190
City	:	BOISE
State	:	ID
Zip	:	83705-7341
Country	:	US
Telephone Number	:	208-343-2737
Fax Number	:	208-342-3238

Provider Business Practice Location Address
First Line	:	315 S JOHNS AVE
Second Line	:
City	:	EMMETT
State	:	ID
Zip	:	83617-3030
Country	:	US
Telephone Number	:	208-343-2737
Fax Number	:	208-342-3238

Authorized Official
Title or Position	:	PRESIDENT AND CEO
Name	:	TAMI JONES
Credential	:	LCSW
Telephone Number	:	208-343-2737

Provider Enumeration Date	:	01/10/2013
Last Update Date	:	01/10/2013

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