Provider Demographics
NPI:1396385845
Name:ALPINE INTEGRATED WELLNESS
Entity Type:Organization
Organization Name:ALPINE INTEGRATED WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:JACOB
Authorized Official - Last Name:ROTHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LCPC
Authorized Official - Phone:503-936-0379
Mailing Address - Street 1:PO BOX 533
Mailing Address - Street 2:
Mailing Address - City:KETCHUM
Mailing Address - State:ID
Mailing Address - Zip Code:83340-0481
Mailing Address - Country:US
Mailing Address - Phone:503-936-0379
Mailing Address - Fax:413-677-2481
Practice Address - Street 1:220 RIVER ST E
Practice Address - Street 2:SUITE D
Practice Address - City:KETCHUM
Practice Address - State:ID
Practice Address - Zip Code:83340
Practice Address - Country:US
Practice Address - Phone:503-936-0379
Practice Address - Fax:413-677-2481
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-13
Last Update Date:2020-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty