Provider Demographics
NPI:1649390998
Name:UNIVERSITY OF IDAHO
Entity Type:Organization
Organization Name:UNIVERSITY OF IDAHO
Other - Org Name:CDHD BEHAVIORAL CONSULTANTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAID BILLING
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HOUSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-885-3771
Mailing Address - Street 1:129 WEST THIRD ST.
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-0000
Mailing Address - Country:US
Mailing Address - Phone:208-885-3771
Mailing Address - Fax:208-885-3628
Practice Address - Street 1:129 WEST THIRD ST.
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-0000
Practice Address - Country:US
Practice Address - Phone:208-885-3771
Practice Address - Fax:208-885-3628
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-30
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002821300Medicaid