Provider Demographics
NPI:1225107923
Name:EMMETT FAMILY SERVICES, LLC
Entity Type:Organization
Organization Name:EMMETT FAMILY SERVICES, LLC
Other - Org Name:PAYETTE FAMILY SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:S
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:208-365-5445
Mailing Address - Street 1:2007 E QUAIL RUN RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:EMMETT
Mailing Address - State:ID
Mailing Address - Zip Code:83617-5059
Mailing Address - Country:US
Mailing Address - Phone:208-365-5445
Mailing Address - Fax:208-365-6226
Practice Address - Street 1:2007 E QUAIL RUN RD
Practice Address - Street 2:SUITE 1
Practice Address - City:EMMETT
Practice Address - State:ID
Practice Address - Zip Code:83617-5059
Practice Address - Country:US
Practice Address - Phone:208-365-5445
Practice Address - Fax:208-365-6226
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2010-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X, 1041C0700X, 363L00000X
NA251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806586200Medicaid
ID807346400Medicaid
ID807360700Medicaid
ID807378100Medicaid
ID806575100Medicaid
ID806598900Medicaid
ID806582400Medicaid
ID806575100Medicaid