Provider Demographics
NPI:1275101776
Name:WHITE PINE VENTURES
Entity Type:Organization
Organization Name:WHITE PINE VENTURES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:HERBERT
Authorized Official - Last Name:BENSON
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:801-999-0580
Mailing Address - Street 1:PO BOX 873
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-0873
Mailing Address - Country:US
Mailing Address - Phone:801-999-0580
Mailing Address - Fax:
Practice Address - Street 1:63 E 1ST S
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-1938
Practice Address - Country:US
Practice Address - Phone:801-999-0580
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-12
Last Update Date:2021-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty