Provider Demographics
NPI:1568502409
Name:IDAHO DEPT OF HEALTH & WELFARE ITP REGION 4
Entity Type:Organization
Organization Name:IDAHO DEPT OF HEALTH & WELFARE ITP REGION 4
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:J
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:BUS
Authorized Official - Phone:208-334-5523
Mailing Address - Street 1:1720 WESTGATE DR
Mailing Address - Street 2:SUITE B-2
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-7164
Mailing Address - Country:US
Mailing Address - Phone:208-334-0900
Mailing Address - Fax:208-334-0926
Practice Address - Street 1:1720 WESTGATE DR
Practice Address - Street 2:SUITE B-2
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-7164
Practice Address - Country:US
Practice Address - Phone:208-334-0900
Practice Address - Fax:208-334-0926
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2013-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251300000X
ID252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
No251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID0028406Medicaid
ID000010019044OtherBLUE SHIELD
IDHW306OtherBLUE CROSS OF IDAHO