Provider Demographics
NPI:1508646860
Name:GEM STATE THERAPY
Entity Type:Organization
Organization Name:GEM STATE THERAPY
Other - Org Name:GEM STATE WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHUBERT
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:208-615-9828
Mailing Address - Street 1:7245 W POTOMAC DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-9150
Mailing Address - Country:US
Mailing Address - Phone:208-615-9828
Mailing Address - Fax:
Practice Address - Street 1:7245 W POTOMAC DR
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-9150
Practice Address - Country:US
Practice Address - Phone:208-615-9828
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-04
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health