Provider Demographics
NPI:1336466994
Name:MIDLIFE CENTER
Entity Type:Organization
Organization Name:MIDLIFE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLER
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:BOOTHE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-765-5656
Mailing Address - Street 1:912 N BALCONY DR
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-6899
Mailing Address - Country:US
Mailing Address - Phone:208-691-2515
Mailing Address - Fax:208-665-2398
Practice Address - Street 1:1423 N GOVERNMENT WAY
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-3335
Practice Address - Country:US
Practice Address - Phone:208-691-2515
Practice Address - Fax:208-665-2398
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-22
Last Update Date:2010-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW293481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty