Provider Demographics
NPI:1437270097
Name:RATHDRUM COUNSELING CENTER LLC
Entity Type:Organization
Organization Name:RATHDRUM COUNSELING CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:208-687-0538
Mailing Address - Street 1:15636 N HIGHWAY 41
Mailing Address - Street 2:
Mailing Address - City:RATHDRUM
Mailing Address - State:ID
Mailing Address - Zip Code:83858-8710
Mailing Address - Country:US
Mailing Address - Phone:208-687-0538
Mailing Address - Fax:208-687-3185
Practice Address - Street 1:15636 N HIGHWAY 41
Practice Address - Street 2:
Practice Address - City:RATHDRUM
Practice Address - State:ID
Practice Address - Zip Code:83858-8710
Practice Address - Country:US
Practice Address - Phone:208-687-0538
Practice Address - Fax:208-687-3185
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8076548Medicaid