Provider Demographics
NPI:1164542403
Name:CLEARWATER COUNSELING
Entity Type:Organization
Organization Name:CLEARWATER COUNSELING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:R
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:208-743-8101
Mailing Address - Street 1:PO BOX 1123
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-1123
Mailing Address - Country:US
Mailing Address - Phone:208-743-8101
Mailing Address - Fax:208-746-7402
Practice Address - Street 1:318 E MAIN ST
Practice Address - Street 2:
Practice Address - City:GRANGEVILLE
Practice Address - State:ID
Practice Address - Zip Code:83530-2238
Practice Address - Country:US
Practice Address - Phone:208-983-7717
Practice Address - Fax:208-983-7787
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-30
Last Update Date:2009-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807373700Medicaid