Provider Demographics
NPI:1588199277
Name:PRIDE MENTAL HEALTH
Entity type:Organization
Organization Name:PRIDE MENTAL HEALTH
Other - Org Name:<UNAVAIL>
Other - Org Type:
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:208-322-2928
Mailing Address - Street 1:9488 W FAIRVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-8101
Mailing Address - Country:US
Mailing Address - Phone:208-322-2928
Mailing Address - Fax:208-322-2983
Practice Address - Street 1:9488 W FAIRVIEW AVE
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8101
Practice Address - Country:US
Practice Address - Phone:208-322-2929
Practice Address - Fax:208-322-2983
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-01
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty