Provider Demographics
NPI:1093040917
Name:PEREGRINE CORP, PC
Entity Type:Organization
Organization Name:PEREGRINE CORP, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOARD PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:DORLEA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:KNIZLEY
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:208-448-4855
Mailing Address - Street 1:PO BOX 205
Mailing Address - Street 2:
Mailing Address - City:PRIEST RIVER
Mailing Address - State:ID
Mailing Address - Zip Code:83856-0205
Mailing Address - Country:US
Mailing Address - Phone:208-448-4855
Mailing Address - Fax:208-448-2467
Practice Address - Street 1:37 HIGHWAY 57
Practice Address - Street 2:
Practice Address - City:PRIEST RIVER
Practice Address - State:ID
Practice Address - Zip Code:83856-6559
Practice Address - Country:US
Practice Address - Phone:208-448-4855
Practice Address - Fax:208-448-2467
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-09
Last Update Date:2013-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC - 139101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807375500Medicaid
Q2776OtherBLUE CROSS OF IDAHO
000010016976OtherREGENCE BLUESHIELD
ID807348800Medicaid