Provider Demographics
NPI:1639116627
Name:COUNSELING CENTER OF SOUTHEAST IDAHO
Entity Type:Organization
Organization Name:COUNSELING CENTER OF SOUTHEAST IDAHO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:A
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:208-552-7100
Mailing Address - Street 1:496 A ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402-3617
Mailing Address - Country:US
Mailing Address - Phone:208-552-7100
Mailing Address - Fax:208-552-7101
Practice Address - Street 1:496 A ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-3617
Practice Address - Country:US
Practice Address - Phone:208-552-7100
Practice Address - Fax:208-552-7101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-31
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1378585Medicare ID - Type UnspecifiedCLINIC GROUP #