Provider Demographics
NPI:1164563508
Name:IDAHO DEPT OF HEALTH & WELFARE ITP REGION 6
Entity Type:Organization
Organization Name:IDAHO DEPT OF HEALTH & WELFARE ITP REGION 6
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:J
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:BUS
Authorized Official - Phone:208-334-5523
Mailing Address - Street 1:421 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4008
Mailing Address - Country:US
Mailing Address - Phone:208-234-7900
Mailing Address - Fax:208-236-6328
Practice Address - Street 1:421 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4008
Practice Address - Country:US
Practice Address - Phone:208-234-7900
Practice Address - Fax:208-236-6328
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2013-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251300000X
ID252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
No251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010019386OtherBLUE SHIELD
ID0028414Medicaid
IDHW165OtherBLUE CROSS OF IDAHO