Provider Demographics
NPI:1619534609
Name:HAVEN BEHAVIORAL OUTPATIENT SERVICES OF BOISE, LLC
Entity Type:Organization
Organization Name:HAVEN BEHAVIORAL OUTPATIENT SERVICES OF BOISE, LLC
Other - Org Name:COTTONWOOD CREEK WELLNESS CENTER - LOST RIVER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP, CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:JANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:PICKLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-393-8809
Mailing Address - Street 1:3102 W END AVE STE 1000
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37203-1324
Mailing Address - Country:US
Mailing Address - Phone:615-393-8800
Mailing Address - Fax:
Practice Address - Street 1:1919 W STATE ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-3958
Practice Address - Country:US
Practice Address - Phone:208-813-6246
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-24
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)