Provider Demographics
NPI:1609267715
Name:STATE OF IDAHO DEPARTMENT OF HEALTH AND WELFARE
Entity Type:Organization
Organization Name:STATE OF IDAHO DEPARTMENT OF HEALTH AND WELFARE
Other - Org Name:SHS PSYCHIATRIC GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PATIENT ACCOUNT SPEC
Authorized Official - Prefix:MS
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:D
Authorized Official - Last Name:SHIELDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-785-8462
Mailing Address - Street 1:P.O. BOX 400
Mailing Address - Street 2:
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221
Mailing Address - Country:US
Mailing Address - Phone:208-785-8462
Mailing Address - Fax:208-785-8518
Practice Address - Street 1:700 EAST ALICE
Practice Address - Street 2:
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221
Practice Address - Country:US
Practice Address - Phone:208-785-8462
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STATE OF IDAHO DEPARTMENT OF HEALTH AND WEL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-02-11
Last Update Date:2015-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty