Provider Demographics
NPI:1366827255
Name:RIVERSIDE RECOVERY LLC
Entity Type:Organization
Organization Name:RIVERSIDE RECOVERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CLINICAL SUPERVISOR/CLINICIAN
Authorized Official - Prefix:
Authorized Official - First Name:SARA
Authorized Official - Middle Name:LIGHT
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:MED, LCPC, CADC
Authorized Official - Phone:208-746-4097
Mailing Address - Street 1:1720 18TH AVE
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-4047
Mailing Address - Country:US
Mailing Address - Phone:208-746-4097
Mailing Address - Fax:208-746-2294
Practice Address - Street 1:1720 18TH AVE
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-4047
Practice Address - Country:US
Practice Address - Phone:208-746-4097
Practice Address - Fax:208-746-2294
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-21
Last Update Date:2015-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC-2714101YA0400X
IDLCPC-5714101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty