Provider Demographics
NPI:1093332207
Name:RIVER WELLNESS CENTER PLLC
Entity Type:Organization
Organization Name:RIVER WELLNESS CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMBER
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:208-731-2896
Mailing Address - Street 1:2216 SETTLERS LN
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-7889
Mailing Address - Country:US
Mailing Address - Phone:208-731-2896
Mailing Address - Fax:
Practice Address - Street 1:139 RIVER VISTA PL STE 106C
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-3060
Practice Address - Country:US
Practice Address - Phone:208-731-0664
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-03
Last Update Date:2020-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDLCSW-39383OtherSTATE LICENSE NUMBER