Provider Demographics
NPI:1154464394
Name:HEALTHY PLACE COUNSELING POCATELLO LLC
Entity Type:Organization
Organization Name:HEALTHY PLACE COUNSELING POCATELLO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KIRK
Authorized Official - Middle Name:
Authorized Official - Last Name:KORENKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-200-4818
Mailing Address - Street 1:1023 YELLOWSTONE AVE
Mailing Address - Street 2:STE. J
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4478
Mailing Address - Country:US
Mailing Address - Phone:208-233-1276
Mailing Address - Fax:208-233-0835
Practice Address - Street 1:1023 YELLOWSTONE AVE
Practice Address - Street 2:STE. J
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4478
Practice Address - Country:US
Practice Address - Phone:208-233-1276
Practice Address - Fax:208-233-0835
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2016-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807364700Medicaid