Provider Demographics
NPI:1275944498
Name:CENTRAL IDAHO COUNSELING, PLLC
Entity Type:Organization
Organization Name:CENTRAL IDAHO COUNSELING, PLLC
Other - Org Name:CENTRAL IDAHO COUNSELING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/CLINICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:A
Authorized Official - Last Name:MIKKELSON
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:208-634-2962
Mailing Address - Street 1:125 COMMERCE ST.
Mailing Address - Street 2:SUITE B
Mailing Address - City:MCCALL
Mailing Address - State:ID
Mailing Address - Zip Code:83638
Mailing Address - Country:US
Mailing Address - Phone:208-634-2962
Mailing Address - Fax:208-634-5064
Practice Address - Street 1:125 COMMERCE ST.
Practice Address - Street 2:SUITE B
Practice Address - City:MCCALL
Practice Address - State:ID
Practice Address - Zip Code:83638
Practice Address - Country:US
Practice Address - Phone:208-634-2962
Practice Address - Fax:208-634-5064
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-09
Last Update Date:2016-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID1041C0700X
IDLMFT-6050106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID20002621OtherPROVIDER TRANSACTION ACCESS NUMBER
ID488228600C1Medicaid