Provider Demographics
NPI:1164550455
Name:IDAHO DEPT OF HEALTH & WELFARE REG 1 CMH PSR CDA
Entity Type:Organization
Organization Name:IDAHO DEPT OF HEALTH & WELFARE REG 1 CMH PSR CDA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CORA JO
Authorized Official - Middle Name:
Authorized Official - Last Name:GUSSENHOVEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-769-1406
Mailing Address - Street 1:1250 IRONWOOD DR STE 100
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2628
Mailing Address - Country:US
Mailing Address - Phone:208-769-1515
Mailing Address - Fax:208-666-6744
Practice Address - Street 1:1250 IRONWOOD DR STE 100
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2628
Practice Address - Country:US
Practice Address - Phone:208-769-1515
Practice Address - Fax:208-666-6744
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
HW199OtherBLUE CROSS OF IDAHO
000010018348OtherBLUE SHIELD
ID0028408Medicaid