MEDICARE: IDAHO DEPT OF HEALTH & WELFARE REGION 4 CMH PSR BOISE

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	261QR0400X	Rehabilitation Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	000010019129	OTHER	BLUE SHIELD
2	HW090	OTHER	BLUE CROSS OF IDAHO
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1891825824
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IDAHO DEPT OF HEALTH & WELFARE REGION 4 CMH PSR BOISE

Provider Business Mailing Address
First Line	:	1720 WESTGATE DR
Second Line	:	SUITE D
City	:	BOISE
State	:	ID
Zip	:	83704-7164
Country	:	US
Telephone Number	:	208-334-0792
Fax Number	:	208-334-0812

Provider Business Practice Location Address
First Line	:	1720 WESTGATE DR
Second Line	:	SUITE D
City	:	BOISE
State	:	ID
Zip	:	83704-7164
Country	:	US
Telephone Number	:	208-334-0792
Fax Number	:	208-334-0812

Authorized Official
Title or Position	:	PROGRAM MANAGER
Name	:	GINA WESTCOTT
Credential	:	M.A.
Telephone Number	:	208-334-0969

Provider Enumeration Date	:	03/07/2007
Last Update Date	:	08/22/2020

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Directions to “IDAHO DEPT OF HEALTH & WELFARE REGION 4 CMH PSR BOISE ” Practice Location

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