Provider Demographics
NPI:1609902980
Name:REGENTS OF THE UNIVERSITY OF IDAHO CHILD & YOUTH STUDY CENTER
Entity Type:Organization
Organization Name:REGENTS OF THE UNIVERSITY OF IDAHO CHILD & YOUTH STUDY CENTER
Other - Org Name:CHILD & YOUTH STUDY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GWEN
Authorized Official - Middle Name:ELAINE
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:LPC, NCSP
Authorized Official - Phone:208-885-6191
Mailing Address - Street 1:875 PERIMETER DRIVE
Mailing Address - Street 2:MS 4061
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83844-4061
Mailing Address - Country:US
Mailing Address - Phone:208-885-3588
Mailing Address - Fax:208-885-3536
Practice Address - Street 1:121 WEST SWEET AVENUE
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843
Practice Address - Country:US
Practice Address - Phone:208-885-6191
Practice Address - Fax:208-885-6188
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-23
Last Update Date:2014-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807220700Medicaid