Provider Demographics
NPI:1184856221
Name:MICHELE OSMOND
Entity Type:Organization
Organization Name:MICHELE OSMOND
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARDEE
Authorized Official - Middle Name:
Authorized Official - Last Name:HARPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-529-4673
Mailing Address - Street 1:2001 S WOODRUFF AVE STE 6
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-6371
Mailing Address - Country:US
Mailing Address - Phone:208-529-4673
Mailing Address - Fax:208-529-4676
Practice Address - Street 1:2001 S WOODRUFF AVE STE 6
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6371
Practice Address - Country:US
Practice Address - Phone:208-529-4673
Practice Address - Fax:208-529-4676
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CLUB, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-08-21
Last Update Date:2009-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC-3303101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty