Provider Demographics
NPI:1588199277
Name:PRIDE MENTAL HEALTH LLC
Entity Type:Organization
Organization Name:PRIDE MENTAL HEALTH LLC
Other - Org Name:PRIDE MENTAL HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DANE
Authorized Official - Middle Name:M
Authorized Official - Last Name:MULLEN
Authorized Official - Suffix:
Authorized Official - Credentials:BS, CPRP
Authorized Official - Phone:208-899-1510
Mailing Address - Street 1:1553 N MILWAUKEE ST
Mailing Address - Street 2:SUITE 310
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-8471
Mailing Address - Country:US
Mailing Address - Phone:208-899-1510
Mailing Address - Fax:
Practice Address - Street 1:8310 W USTICK RD
Practice Address - Street 2:SUITE 300
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-5979
Practice Address - Country:US
Practice Address - Phone:208-899-1510
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-01
Last Update Date:2017-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management