Provider Demographics
NPI:1083773378
Name:NORTH IDAHO CHILDREN'S MENTAL HEALTH, PLLC.
Entity Type:Organization
Organization Name:NORTH IDAHO CHILDREN'S MENTAL HEALTH, PLLC.
Other - Org Name:NICMH
Other - Org Type:Other Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:BENDICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-265-6798
Mailing Address - Street 1:1717 W. ONTARIO ST
Mailing Address - Street 2:
Mailing Address - City:SANDPOINT
Mailing Address - State:ID
Mailing Address - Zip Code:83864-8268
Mailing Address - Country:US
Mailing Address - Phone:208-265-6798
Mailing Address - Fax:208-263-8160
Practice Address - Street 1:1717 ONTARIO ST
Practice Address - Street 2:
Practice Address - City:SANDPOINT
Practice Address - State:ID
Practice Address - Zip Code:83864-9329
Practice Address - Country:US
Practice Address - Phone:208-265-6798
Practice Address - Fax:208-263-8160
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2010-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-254931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806106400Medicaid
ID1374294Medicare PIN