Provider Demographics
NPI:1427179746
Name:SANDPOINT PSYCHOTHERAPY LLC
Entity Type:Organization
Organization Name:SANDPOINT PSYCHOTHERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER AND LEAD CLINICIAN
Authorized Official - Prefix:MS
Authorized Official - First Name:ELEANOR
Authorized Official - Middle Name:RAND
Authorized Official - Last Name:GURELY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW,DAPA
Authorized Official - Phone:208-263-5393
Mailing Address - Street 1:506 N 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:SANDPOINT
Mailing Address - State:ID
Mailing Address - Zip Code:83864-1513
Mailing Address - Country:US
Mailing Address - Phone:208-263-5393
Mailing Address - Fax:208-265-2301
Practice Address - Street 1:506 N 4TH AVE
Practice Address - Street 2:
Practice Address - City:SANDPOINT
Practice Address - State:ID
Practice Address - Zip Code:83864-1513
Practice Address - Country:US
Practice Address - Phone:208-263-5393
Practice Address - Fax:208-265-2301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-1358101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806654400Medicaid