Provider Demographics
NPI:1093354318
Name:COUNSELING & TREATMENT CENTER OF IDAHO, LLC
Entity Type:Organization
Organization Name:COUNSELING & TREATMENT CENTER OF IDAHO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:
Authorized Official - Last Name:FINCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-857-9136
Mailing Address - Street 1:859 S YELLOWSTONE HWY STE 302
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-5294
Mailing Address - Country:US
Mailing Address - Phone:208-932-5363
Mailing Address - Fax:205-273-8403
Practice Address - Street 1:859 S YELLOWSTONE HWY STE 302
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-5294
Practice Address - Country:US
Practice Address - Phone:208-932-5363
Practice Address - Fax:205-273-8403
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-03
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDIDTPID012974Medicaid