Provider Demographics
NPI:1235791997
Name:METAMORPHOSIS COUNSELING AND HEALTH CENTER OF IDAHO, LLC
Entity Type:Organization
Organization Name:METAMORPHOSIS COUNSELING AND HEALTH CENTER OF IDAHO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:208-376-1532
Mailing Address - Street 1:10108 W OVERLAND RD # A
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-1428
Mailing Address - Country:US
Mailing Address - Phone:208-376-1532
Mailing Address - Fax:208-375-7251
Practice Address - Street 1:10108 W OVERLAND RD # A
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-1428
Practice Address - Country:US
Practice Address - Phone:208-376-1532
Practice Address - Fax:208-375-7251
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:1235791997
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-07-02
Last Update Date:2023-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No172V00000XOther Service ProvidersCommunity Health WorkerGroup - Multi-Specialty
No175T00000XOther Service ProvidersPeer SpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDUNKNOWNMedicaid