Provider Demographics
NPI:1497116099
Name:ABUNDANCE BEHAVIORAL HEALTH SERVICES, INC
Entity Type:Organization
Organization Name:ABUNDANCE BEHAVIORAL HEALTH SERVICES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:BEVERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:LSW-I
Authorized Official - Phone:208-455-1222
Mailing Address - Street 1:524 E CLEVELAND BLVD
Mailing Address - Street 2:STE 230
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83605
Mailing Address - Country:US
Mailing Address - Phone:208-455-1222
Mailing Address - Fax:208-455-2559
Practice Address - Street 1:524 CLEVELAND BLVD
Practice Address - Street 2:STE 230
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-4076
Practice Address - Country:US
Practice Address - Phone:208-455-1222
Practice Address - Fax:208-455-2559
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-10
Last Update Date:2016-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1669795308Medicaid