Provider Demographics
NPI:1073660320
Name:PRIESTLEY MENTAL HEALTH INC
Entity Type:Organization
Organization Name:PRIESTLEY MENTAL HEALTH INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:PRIESTLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-339-0227
Mailing Address - Street 1:PO BOX 54
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:ID
Mailing Address - Zip Code:83237-0054
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:75 S 1ST W
Practice Address - Street 2:
Practice Address - City:PRESTON
Practice Address - State:ID
Practice Address - Zip Code:83263-1259
Practice Address - Country:US
Practice Address - Phone:208-852-2370
Practice Address - Fax:208-852-5570
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-05
Last Update Date:2013-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID26656104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806081800Medicaid