Provider Demographics
NPI:1285029496
Name:NEW HORIZONS MENTAL WELLNESS CLINICS PLLC
Entity Type:Organization
Organization Name:NEW HORIZONS MENTAL WELLNESS CLINICS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DARRIN
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTSON
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP-BC
Authorized Official - Phone:208-233-2025
Mailing Address - Street 1:1352 E CENTER ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4734
Mailing Address - Country:US
Mailing Address - Phone:208-233-2025
Mailing Address - Fax:208-233-2178
Practice Address - Street 1:1352 E CENTER ST
Practice Address - Street 2:SUITE A
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4734
Practice Address - Country:US
Practice Address - Phone:208-233-2025
Practice Address - Fax:208-233-2178
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-03
Last Update Date:2015-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP1034A163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WC0400XNursing Service ProvidersRegistered NurseCase ManagementGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1750621116Medicaid