Provider Demographics
NPI:1598959322
Name:MOUNTAIN STATES COUNSELING & PSYCHOLOGICAL SERVICES PLLL
Entity Type:Organization
Organization Name:MOUNTAIN STATES COUNSELING & PSYCHOLOGICAL SERVICES PLLL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CLAY
Authorized Official - Middle Name:H
Authorized Official - Last Name:WARD
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:208-375-6402
Mailing Address - Street 1:311 ALLUMBAUGH ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-9208
Mailing Address - Country:US
Mailing Address - Phone:208-375-6402
Mailing Address - Fax:208-323-1850
Practice Address - Street 1:311 ALLUMBAUGH ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-9208
Practice Address - Country:US
Practice Address - Phone:208-375-6402
Practice Address - Fax:208-323-1850
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-05
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPSY61103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID85902OtherBLUE CROSS OF IDAHO
ID10015901OtherREGENCE BLUE SHIELD
ID=========OtherCHAMPUS
ID10015901OtherREGENCE BLUE SHIELD