Provider Demographics
NPI:1003113465
Name:BLACKFOOT BEHAVIORAL HEALTH, LLC
Entity Type:Organization
Organization Name:BLACKFOOT BEHAVIORAL HEALTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SANDEE
Authorized Official - Middle Name:
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:208-680-0542
Mailing Address - Street 1:75 LILAC ST
Mailing Address - Street 2:
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221-1768
Mailing Address - Country:US
Mailing Address - Phone:208-782-1322
Mailing Address - Fax:208-782-1074
Practice Address - Street 1:75 LILAC ST
Practice Address - Street 2:
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221-1768
Practice Address - Country:US
Practice Address - Phone:208-782-1322
Practice Address - Fax:208-782-1074
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-22
Last Update Date:2011-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW26332323P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility