Provider Demographics
NPI:1558404129
Name:HUMAN SUPPORTS OF IDAHO, INC.
Entity Type:Organization
Organization Name:HUMAN SUPPORTS OF IDAHO, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:L
Authorized Official - Last Name:DICKERSON
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:208-321-0160
Mailing Address - Street 1:PO BOX 820
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83606-0820
Mailing Address - Country:US
Mailing Address - Phone:208-454-8389
Mailing Address - Fax:208-454-8404
Practice Address - Street 1:4477 W EMERALD ST
Practice Address - Street 2:STE C-100
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-2000
Practice Address - Country:US
Practice Address - Phone:208-321-0160
Practice Address - Fax:208-321-0221
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2012-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002800000Medicaid