Provider Demographics
NPI:1407549041
Name:HEALING HUB LLC
Entity Type:Organization
Organization Name:HEALING HUB LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ASHTON
Authorized Official - Middle Name:
Authorized Official - Last Name:UNDERDAHL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-691-0691
Mailing Address - Street 1:2680 E HAYDEN VIEW DR
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83815-7038
Mailing Address - Country:US
Mailing Address - Phone:208-691-0691
Mailing Address - Fax:
Practice Address - Street 1:8677 N WAYNE DR STE B
Practice Address - Street 2:
Practice Address - City:HAYDEN
Practice Address - State:ID
Practice Address - Zip Code:83835-5190
Practice Address - Country:US
Practice Address - Phone:208-691-0691
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-30
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1669956686Medicaid