Provider Demographics
NPI:1083152144
Name:RATHDRUM COUNSELING CENTER, LLC
Entity Type:Organization
Organization Name:RATHDRUM COUNSELING CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:M
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:208-687-0538
Mailing Address - Street 1:14954 N COEUR DALENE ST
Mailing Address - Street 2:
Mailing Address - City:RATHDRUM
Mailing Address - State:ID
Mailing Address - Zip Code:83858-6484
Mailing Address - Country:US
Mailing Address - Phone:208-687-0538
Mailing Address - Fax:208-687-3185
Practice Address - Street 1:14954 N COEUR DALENE ST
Practice Address - Street 2:
Practice Address - City:RATHDRUM
Practice Address - State:ID
Practice Address - Zip Code:83858-6484
Practice Address - Country:US
Practice Address - Phone:208-687-0538
Practice Address - Fax:208-687-3185
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-08
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW 362801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1437270097Medicaid
ID1437270097Medicaid