Provider Demographics
NPI:1053658138
Name:IDAHO BEHAVIORAL HEALTH, INC.
Entity Type:Organization
Organization Name:IDAHO BEHAVIORAL HEALTH, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:
Authorized Official - First Name:TAMI
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:208-343-2737
Mailing Address - Street 1:2273 S VISTA AVE
Mailing Address - Street 2:#190
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83705-7341
Mailing Address - Country:US
Mailing Address - Phone:208-343-2737
Mailing Address - Fax:208-342-3238
Practice Address - Street 1:2420 AMERICAN LEGION BLVD
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:ID
Practice Address - Zip Code:83647-3146
Practice Address - Country:US
Practice Address - Phone:208-580-9525
Practice Address - Fax:208-580-9527
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-10
Last Update Date:2013-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-4112207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty