Provider Demographics
NPI:1619503893
Name:OPEN TRAILS COUNSELING AND CONSULTING PLLC
Entity Type:Organization
Organization Name:OPEN TRAILS COUNSELING AND CONSULTING PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOANNA
Authorized Official - Middle Name:L
Authorized Official - Last Name:TRUSSEL BERG
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:208-521-9946
Mailing Address - Street 1:PO BOX 372
Mailing Address - Street 2:
Mailing Address - City:RIGBY
Mailing Address - State:ID
Mailing Address - Zip Code:83442-0372
Mailing Address - Country:US
Mailing Address - Phone:208-521-9946
Mailing Address - Fax:
Practice Address - Street 1:1689 E 113 S
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7785
Practice Address - Country:US
Practice Address - Phone:208-521-9946
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-19
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty